=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922423474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL NUZUM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2014
-----------------------------------------------------
Last Update Date | 02/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 9TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-461-1112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 319 9TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-461-1112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | 2013
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------