=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043380769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICHOLS THERAPY GROUP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 06/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9652 W STATE STREET
-----------------------------------------------------
City | STAR
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83669-5858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-286-0766
-----------------------------------------------------
Fax | 208-286-0768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9652 W STATE STREET
-----------------------------------------------------
City | STAR
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83669-5858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-286-0766
-----------------------------------------------------
Fax | 208-286-0768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BRIAN DAVID NICHOLS
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 208-286-0766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | RPT1371
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | RPT1136
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1136
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------