=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659963890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS M DORE PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2021
-----------------------------------------------------
Last Update Date | 02/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 GABRIEL WAY
-----------------------------------------------------
City | SULPHUR ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72579-9012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-656-8646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 GABRIEL WAY
-----------------------------------------------------
City | SULPHUR ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72579-9012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-656-8646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | L.AC.023
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------