MEDICARE: TRACEY RENEE NICHOLLS L.AC

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	171100000X	Acupuncturist	ACU0001916	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720590615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY RENEE NICHOLLS L.AC

Provider Business Mailing Address
First Line	:	PO BOX 296
Second Line	:
City	:	BEULAH
State	:	CO
Zip	:	81023-0296
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 FORTINO BLVD STE A
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-2377
Country	:	US
Telephone Number	:	719-582-1010
Fax Number	:	719-582-1010

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

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	01/28/2026

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Directions to “ TRACEY RENEE NICHOLLS L.AC” Practice Location

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