Individual
CHARLES WAYNE NICHOLS JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
855 MONTGOMERY ST, FORT WORTH, TX 76107-2553
(817) 735-3627
Mailing address
PO BOX 99335, FORT WORTH, TX 76199-0335
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1046365
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036784902
—
TX
01
—
875T14
BCBS
TX
Enumeration date
06/25/2007
Last updated
10/22/2012
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