=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902881873
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON GRAVES NICELY D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 03/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 CASTALIA ST SUITE G
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44811-1181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-484-9070
-----------------------------------------------------
Fax | 419-484-9070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 CASTALIA ST SUITE G
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44811-1181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-484-9070
-----------------------------------------------------
Fax | 419-484-9070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3071
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------