Provider Demographics
NPI:1962624130
Name:NICHOLS, ROBERT KENNETH (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KENNETH
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 1:4700 RICHMOND RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5985
Mailing Address - Country:US
Mailing Address - Phone:216-378-9390
Mailing Address - Fax:
Practice Address - Street 1:4700 RICHMOND RD
Practice Address - Street 2:STE 100
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-5985
Practice Address - Country:US
Practice Address - Phone:216-378-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2054111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0960385Medicaid
U48384Medicare UPIN
OHNI0757321Medicare ID - Type Unspecified