Healthcare Provider Details

I. General information

NPI: 1780153635
Provider Name (Legal Business Name): NICKOLAS CULPEPPER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 SIERRA CENTER PKWY
RENO NV
89511-2209
US

IV. Provider business mailing address

11135 MESSINA WAY
RENO NV
89521-4249
US

V. Phone/Fax

Practice location:
  • Phone: 775-393-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICKOLAS CULPEPPER
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 706-832-6922