Healthcare Provider Details

I. General information

NPI: 1053432294
Provider Name (Legal Business Name): CHARLES GEORGE NICOLA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 KENNEDY BLVD
JERSEY CITY NJ
07304
US

IV. Provider business mailing address

11 HIRAM SQ
NEW BRUNSWICK NJ
08901-1271
US

V. Phone/Fax

Practice location:
  • Phone: 201-434-2855
  • Fax:
Mailing address:
  • Phone: 732-246-4226
  • Fax: 732-246-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number38MC00470400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: