MEDICARE: NICHOLE MADDOCK

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	171M00000X	Case Manager/Care Coordinator
2	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1447947783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE MADDOCK

Provider Business Mailing Address
First Line	:	2210 N ELDORADO AVE
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-6418
Country	:	US
Telephone Number	:	541-883-1030
Fax Number	:

Provider Business Practice Location Address
First Line	:	3203 VANDENBERG RD
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-3778
Country	:	US
Telephone Number	:	541-883-1030
Fax Number	:

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

Provider Enumeration Date	:	04/18/2023
Last Update Date	:	04/18/2023

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Directions to “ NICHOLE MADDOCK ” Practice Location

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