Healthcare Provider Details

I. General information

NPI: 1093056103
Provider Name (Legal Business Name): NICHOLAS MICHAEL SMITH DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 MEYER RD
WEST SENECA NY
14224-1954
US

IV. Provider business mailing address

425 MEYER RD
WEST SENECA NY
14224-1954
US

V. Phone/Fax

Practice location:
  • Phone: 716-677-4022
  • Fax:
Mailing address:
  • Phone: 716-677-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0011807
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number035839
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number035839
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: