Provider Demographics
NPI:1295582112
Name:NICHOLS, MARK DANIEL JR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:NICHOLS
Suffix:JR
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 1:973 SEDAN CRABTREE RD
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8960
Mailing Address - Country:US
Mailing Address - Phone:740-935-7753
Mailing Address - Fax:
Practice Address - Street 1:923 SEDAN CRABTREE RD UNIT C
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-9314
Practice Address - Country:US
Practice Address - Phone:740-259-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant