Healthcare Provider Details

I. General information

NPI: 1538538913
Provider Name (Legal Business Name): JEREMY NICHOLOPOULOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 OLD ALICE RD SUITE 600
BROWNSVILLE TX
78520-8268
US

IV. Provider business mailing address

871 OLD ALICE RD SUITE 600
BROWNSVILLE TX
78520-8268
US

V. Phone/Fax

Practice location:
  • Phone: 956-541-2102
  • Fax: 956-541-2502
Mailing address:
  • Phone: 956-541-2102
  • Fax: 956-541-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA5024
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2090772
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: