Provider Demographics
NPI:1972994697
Name:SCRUGGS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SCRUGGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BAGLEY ST
Mailing Address - Street 2:SUITE 518
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1400
Mailing Address - Country:US
Mailing Address - Phone:313-778-8501
Mailing Address - Fax:
Practice Address - Street 1:220 BAGLEY ST
Practice Address - Street 2:SUITE 518
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1400
Practice Address - Country:US
Practice Address - Phone:313-778-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173C00000X
MI7501008135175L00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No175L00000XOther Service ProvidersHomeopath