Provider Demographics
NPI:1124139308
Name:ANDERSON, NICHOLE C (DC)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234
Mailing Address - Country:US
Mailing Address - Phone:313-891-1800
Mailing Address - Fax:313-891-1802
Practice Address - Street 1:3702 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234
Practice Address - Country:US
Practice Address - Phone:313-891-1800
Practice Address - Fax:313-891-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480131314Medicaid
MI95OH225940OtherBCBS
MIOP26530Medicare ID - Type Unspecified