Individual
MR. BRIAN DAVID NICHOLS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MPT ATC
Contact information
Practice address
9652 W STATE STREET, STAR, ID 83669-5858
(208) 286-0766
(208) 286-0768
Mailing address
9652 W STATE STREET, STAR, ID 83669-5858
(208) 286-0766
(208) 286-0768
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
1136
ID
225100000X
Physical Therapist
Primary
RPT1136
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010147595
REGENCE BLUE SHIELD
ID
05
—
806941900
—
ID
01
—
TA229
BLUE CROSS #
ID
Enumeration date
09/15/2006
Last updated
07/02/2012
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