MEDICARE: NICOLE MARIE HAVEL ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083S0010X	Sports Medicine (Preventive Medicine) Physician	2000029048	IA

General Provider Information

NPI Number	:	1083127104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE HAVEL ATC

Provider Business Mailing Address
First Line	:	203 ERIC AVE
Second Line	:
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-2690
Country	:	US
Telephone Number	:	847-494-6409
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 BUCHTEL BLVD
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-3447
Country	:	US
Telephone Number	:	847-494-6409
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2017
Last Update Date	:	11/11/2017

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