=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568703908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICKELS NATURAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2013
-----------------------------------------------------
Last Update Date | 03/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E MCLOUGHLIN BLVD SUITE B
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98663-3366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-818-4218
-----------------------------------------------------
Fax | 360-859-4536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 E MCLOUGHLIN BLVD SUITE B
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98663-3366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-818-4218
-----------------------------------------------------
Fax | 360-859-4536
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, NATUROPATHIC PHYSICIAN
-----------------------------------------------------
Name | DR. MELINDA NICKELS
-----------------------------------------------------
Credential | N.D., L.AC
-----------------------------------------------------
Telephone | 360-818-4218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC60054014
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC01291
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 1669
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | NT60051160
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------