MEDICARE: MR. NICHOLAS J TILTON ATC

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1932611290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS J TILTON ATC

Provider Business Mailing Address
First Line	:	925 CITY CENTRAL AVE
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2981
Country	:	US
Telephone Number	:	936-202-5202
Fax Number	:	936-202-5230

Provider Business Practice Location Address
First Line	:	19939 CHASEWOOD PARK DR APT 9211
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-1154
Country	:	US
Telephone Number	:	603-553-8668
Fax Number	:

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

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	02/13/2023

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