Healthcare Provider Details

I. General information

NPI: 1144304320
Provider Name (Legal Business Name): NICHOLAS MICELI D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAVERLY AVE SUITE 9
PATCHOGUE NY
11772-1555
US

IV. Provider business mailing address

450 WAVERLY AVE SUITE 9
PATCHOGUE NY
11772-1555
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-1151
  • Fax: 631-289-1159
Mailing address:
  • Phone: 631-289-1151
  • Fax: 631-289-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX003364-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierC003364-9
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerWORKER'S COMPENSATON

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: