Healthcare Provider Details

I. General information

NPI: 1871167304
Provider Name (Legal Business Name): NICOLAS ST. CLAIR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 07/04/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WIGWAM PKWY STE 240
HENDERSON NV
89074-8195
US

IV. Provider business mailing address

1250 WIGWAM PKWY UNIT 3112
HENDERSON NV
89074-8357
US

V. Phone/Fax

Practice location:
  • Phone: 702-568-0195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: