Healthcare Provider Details

I. General information

NPI: 1972997625
Provider Name (Legal Business Name): NICHOLAS MEEHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 POLO RD
COLUMBIA SC
29223
US

IV. Provider business mailing address

731 POLO RD
COLUMBIA SC
29223
US

V. Phone/Fax

Practice location:
  • Phone: 803-419-0431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3419
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: