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General NPI Number Information
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NPI Number | 1578352571
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Entity Type | Individual
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Provider Name | NICKOLES LONG
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Gender | Male
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Dates
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Enumeration Date | 05/05/2025
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 800 YARD ST STE 300
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City | GRANDVIEW HEIGHTS
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State | OH
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Zip | 43212-3882
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Country | US
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Telephone | 937-672-6098
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Fax |
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Provider Business Mailing Address
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Address Line | 5057 DRIVEMERE RD
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City | HILLIARD
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State | OH
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Zip | 43026-1514
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Country | US
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Telephone | 937-672-6098
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT018726
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License Number State | OH
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