Provider Demographics
NPI:1063401503
Name:MACK, NICCOLE J (DPT)
Entity type:Individual
Prefix:
First Name:NICCOLE
Middle Name:J
Last Name:MACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICCOLE
Other - Middle Name:J
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:901 4TH ST NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1558
Practice Address - Country:US
Practice Address - Phone:605-886-8471
Practice Address - Fax:605-886-9317
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5834040Medicaid