MEDICARE: NICHOLAS ANGLO

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	171WH0202X	Home Modifications Contractor

General Provider Information

NPI Number	:	1497471015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS ANGLO

Provider Business Mailing Address
First Line	:	3980 RUSH LAKE RD
Second Line	:
City	:	RUSH CITY
State	:	MN
Zip	:	55069-2868
Country	:	US
Telephone Number	:	320-266-5272
Fax Number	:

Provider Business Practice Location Address
First Line	:	3980 RUSH LAKE RD
Second Line	:
City	:	RUSH CITY
State	:	MN
Zip	:	55069-2868
Country	:	US
Telephone Number	:	320-266-5272
Fax Number	:

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

Provider Enumeration Date	:	10/14/2022
Last Update Date	:	10/14/2022

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Directions to “ NICHOLAS ANGLO ” Practice Location

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