MEDICARE: NICKLAUS JAMES MCCALLUM

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	225700000X	Massage Therapist	0000012412	TN

General Provider Information

NPI Number	:	1992446272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKLAUS JAMES MCCALLUM

Provider Business Mailing Address
First Line	:	1026 MANSFIELD AVE UNIT B
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37206-3516
Country	:	US
Telephone Number	:	818-404-1091
Fax Number	:

Provider Business Practice Location Address
First Line	:	1026 MANSFIELD AVE UNIT B
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37206-3516
Country	:	US
Telephone Number	:	818-404-1091
Fax Number	:

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

Provider Enumeration Date	:	04/02/2022
Last Update Date	:	04/02/2022

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