MEDICARE: DR. PETER GEORGE NICKLESS D.C

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	111N00000X	Chiropractor	X009869	NY
2	111N00000X	Chiropractor	CR1900	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C09869-1	OTHER	NY	WORKERS COMP ID NUMBER
2	X009869	OTHER	NY	NY STATE LICENSE
3	CR1900	OTHER	ME	MAINE LISCENCE

General Provider Information

NPI Number	:	1154331197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER GEORGE NICKLESS D.C

Provider Business Mailing Address
First Line	:	3239 LAKE RD
Second Line	:
City	:	SENECA FALLS
State	:	NY
Zip	:	13148-9416
Country	:	US
Telephone Number	:	845-367-1171
Fax Number	:

Provider Business Practice Location Address
First Line	:	3239 LAKE RD
Second Line	:
City	:	SENECA FALLS
State	:	NY
Zip	:	13148-9416
Country	:	US
Telephone Number	:	845-367-1171
Fax Number	:

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/06/2013

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