=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568960763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS JOHN NUNLEY ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2018
-----------------------------------------------------
Last Update Date | 01/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 EL MONTE PL
-----------------------------------------------------
City | MANITOU SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80829-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-530-9929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8232 W US HIGHWAY 24
-----------------------------------------------------
City | CASCADE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80809-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT.0001323
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------