Healthcare Provider Details

I. General information

NPI: 1073830352
Provider Name (Legal Business Name): MR. DAVID MICHAEL NICHOLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 E 840 S
OREM UT
84058-5016
US

IV. Provider business mailing address

1451 CORNERSTONE DR
SOUTH JORDAN UT
84095-4533
US

V. Phone/Fax

Practice location:
  • Phone: 801-226-7696
  • Fax: 801-225-7053
Mailing address:
  • Phone: 801-616-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: