Healthcare Provider Details

I. General information

NPI: 1124941141
Provider Name (Legal Business Name): NICHOLUS BLAIR CADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SW FRAZER AVE
PENDLETON OR
97801-2800
US

IV. Provider business mailing address

2426 SW NYE AVE
PENDLETON OR
97801-4371
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-1022
  • Fax:
Mailing address:
  • Phone: 541-310-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18-03-09
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: