MEDICARE: NICOLE LYNN VICARIO PT, DPT

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	225100000X	Physical Therapist	295802	CA

General Provider Information

NPI Number	:	1619447703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LYNN VICARIO PT, DPT

Provider Business Mailing Address
First Line	:	3217 E OLYMPIC DR
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-7278
Country	:	US
Telephone Number	:	909-720-4899
Fax Number	:

Provider Business Practice Location Address
First Line	:	14850 CENTRAL AVE
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-9509
Country	:	US
Telephone Number	:	909-720-4899
Fax Number	:

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

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	11/30/2018

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