=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841976727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS NOBLITT PT, DPT, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2023
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9437 OLIVE BLVD
-----------------------------------------------------
City | OLIVETTE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-989-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3005 SIDNEY ST. #A
-----------------------------------------------------
City | ST. LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2023024470
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------