MEDICARE: NICHOLAS FRANCIS MERCALDO

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	225200000X	Physical Therapy Assistant	4381	SC

General Provider Information

NPI Number	:	1386278216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS FRANCIS MERCALDO

Provider Business Mailing Address
First Line	:	200 ARCHDALE ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7825
Country	:	US
Telephone Number	:	843-902-1911
Fax Number	:

Provider Business Practice Location Address
First Line	:	4871 SOCASTEE BLVD UNIT E
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7252
Country	:	US
Telephone Number	:	843-293-5610
Fax Number	:

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

Provider Enumeration Date	:	03/01/2020
Last Update Date	:	03/01/2020

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