Healthcare Provider Details

I. General information

NPI: 1205428042
Provider Name (Legal Business Name): NICHOLAS HEARST LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 PULASKI DR
KING OF PRUSSIA PA
19406-2802
US

IV. Provider business mailing address

4909 MARKET ST APT 2
PHILADELPHIA PA
19139-3665
US

V. Phone/Fax

Practice location:
  • Phone: 610-640-9355
  • Fax:
Mailing address:
  • Phone: 215-433-5268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMSG012206
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: