Provider Demographics
NPI:1285257782
Name:NICHOLLS, ERIC RYAN
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:RYAN
Last Name:NICHOLLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10017 NITA AVE
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2724
Mailing Address - Country:US
Mailing Address - Phone:818-926-2857
Mailing Address - Fax:
Practice Address - Street 1:10017 NITA AVE
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2724
Practice Address - Country:US
Practice Address - Phone:818-926-2857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10907208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation