Healthcare Provider Details

I. General information

NPI: 1003944810
Provider Name (Legal Business Name): NICHOLAS LOAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 ELM ST
PENN YAN NY
14527-1409
US

IV. Provider business mailing address

335 ELM ST
PENN YAN NY
14527-1409
US

V. Phone/Fax

Practice location:
  • Phone: 315-536-8124
  • Fax: 315-536-6728
Mailing address:
  • Phone: 315-536-8124
  • Fax: 315-536-6728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number004727
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: