Healthcare Provider Details

I. General information

NPI: 1356808463
Provider Name (Legal Business Name): NICOLAS CIVALE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 STATESMAN DR
IRVING TX
75063-2414
US

IV. Provider business mailing address

129 GREENWOODS LN
EAST WINDSOR CT
06088-9692
US

V. Phone/Fax

Practice location:
  • Phone: 469-524-1506
  • Fax:
Mailing address:
  • Phone: 860-372-8013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number011659
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: