=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982567129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICKELSON FAMILY CHIROPRACTIC PROFESSIONAL LIMITED LIABILITY COM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2025
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 S SHADY SHORES DR STE 100
-----------------------------------------------------
City | LAKE DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75065-3663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-435-1164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 314 S SHADY SHORES DR STE 100
-----------------------------------------------------
City | LAKE DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75065-3663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-435-1164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SAMANTHA NICKELSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 940-435-1164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------