Healthcare Provider Details

I. General information

NPI: 1205545019
Provider Name (Legal Business Name): MR. NICKOLAS PAUL BURICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/21/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 OHIO ST
LODI OH
44254-1048
US

IV. Provider business mailing address

116 OHIO ST
LODI OH
44254-1048
US

V. Phone/Fax

Practice location:
  • Phone: 330-691-9187
  • Fax:
Mailing address:
  • Phone: 330-691-9187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number3726000000X
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: