Provider Demographics
NPI:1386308567
Name:MERCADO, NICOLE (DC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MERCADO
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:PO BOX 1083
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-0011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N JOHN REDDITT DR STE 3
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-2634
Practice Address - Country:US
Practice Address - Phone:936-899-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14783111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor