MEDICARE: NICHOLAS SUITE

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	2084N0400X	Neurology Physician	5315029864	MI

General Provider Information

NPI Number	:	1447330048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS SUITE

Provider Business Mailing Address
First Line	:	2525 EMBASSY DR STE 5
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33026-4573
Country	:	US
Telephone Number	:	305-382-1005
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 EMBASSY DR STE 5
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33026-4573
Country	:	US
Telephone Number	:	305-382-1005
Fax Number	:

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	09/14/2021

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Directions to “ NICHOLAS SUITE ” Practice Location

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