Healthcare Provider Details

I. General information

NPI: 1184811804
Provider Name (Legal Business Name): BRUCE MICHAEL NICOARA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 KINGSTON PIKE SUITE 185
KNOXVILLE TN
37934-3803
US

IV. Provider business mailing address

PO BOX 441146
KENNESAW GA
30160-9522
US

V. Phone/Fax

Practice location:
  • Phone: 865-675-2820
  • Fax: 865-675-2821
Mailing address:
  • Phone: 678-403-3632
  • Fax: 678-567-6737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number7915
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: