Healthcare Provider Details

I. General information

NPI: 1588916043
Provider Name (Legal Business Name): MR. NICHOLAS EVAN TIBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 NORTH CENTERLINE DR.
MANTI UT
84642
US

IV. Provider business mailing address

PO BOX 287
MANTI UT
84642-0287
US

V. Phone/Fax

Practice location:
  • Phone: 435-835-4381
  • Fax: 435-835-4380
Mailing address:
  • Phone: 435-835-4381
  • Fax: 435-835-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: