Provider Demographics
NPI:1427889716
Name:ESTACIO, NICHOLAS (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ESTACIO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17071 VENTURA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4142
Mailing Address - Country:US
Mailing Address - Phone:818-232-4884
Mailing Address - Fax:
Practice Address - Street 1:17071 VENTURA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4142
Practice Address - Country:US
Practice Address - Phone:818-232-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist