Provider Demographics
NPI:1841899812
Name:NICHOLS, RYAN (DC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 BRISTOL ST STE C105
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5944
Mailing Address - Country:US
Mailing Address - Phone:714-584-7741
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE C105
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5944
Practice Address - Country:US
Practice Address - Phone:714-584-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty