=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215713813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS R HENES DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2023
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 GREAT OAKS TRL
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-9430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-336-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6321 CHIPPEWA RD
-----------------------------------------------------
City | ORRVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44667-9146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-466-4609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC-05291
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------