Provider Demographics
NPI:1275773111
Name:EICKHOLT, NICHOLE MARIE (MSPT)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:MARIE
Last Name:EICKHOLT
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17272 ROBBINS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417
Mailing Address - Country:US
Mailing Address - Phone:810-733-1200
Mailing Address - Fax:810-733-3130
Practice Address - Street 1:17272 ROBBINS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:810-733-1200
Practice Address - Fax:810-733-3130
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N45090OtherMEDICARE GRP PTAN
MI0N45090OtherMEDICARE GRP PTAN