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General NPI Number Information
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NPI Number | 1194984443
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Entity Type | Individual
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Provider Name | PHIL JAMES NYDEREK SR.
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Gender | Male
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Dates
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Enumeration Date | 06/03/2008
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Last Update Date | 05/12/2015
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Provider Practice Location Address
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Address Line | 103 ASHMOORE DRIVE
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City | GREENUP
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State | KY
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Zip | 41144
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Country | US
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Telephone | 740-821-6973
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Fax | 606-473-1389
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Provider Business Mailing Address
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Address Line | 103 ASHMOORE DRIVE
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City | GREENUP
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State | KY
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Zip | 41144
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Country | US
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Telephone | 740-821-6973
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Fax | 606-473-1389
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171WH0202X
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Taxonomy Name | Home Modifications Contractor
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License Number |
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License Number State |
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