=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942493531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTLOOK CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 08/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MAIN ST NORTH
-----------------------------------------------------
City | MCVILLE
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-322-4328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 385
-----------------------------------------------------
City | COOPERSTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58425-0385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-797-2941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS PATRICK NICOLAI
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 701-797-2941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 656
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------