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General NPI Number Information
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NPI Number | 1912110966
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Entity Type | Individual
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Provider Name | NIKITAS NICHOLAIDES MS, ATC, CSCS, CFST2
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Gender | Male
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 11/02/2011
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Provider Practice Location Address
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Address Line | 627 E RIDGEWOOD AVE
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City | RIDGEWOOD
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State | NJ
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Zip | 07450-3310
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Country | US
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Telephone | 201-670-2800
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Fax |
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Provider Business Mailing Address
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Address Line | 123 HONEYSUCKLE DR
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City | TOWNSHIP OF WASHINGTON
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State | NJ
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Zip | 07676-5263
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Country | US
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Telephone | 201-664-1010
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 25MT00084300
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License Number State | NJ
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