Provider Demographics
NPI:1376622860
Name:NICHOLS, JOSEPH JOHN III (MPT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JOHN
Last Name:NICHOLS
Suffix:III
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:28535 DUPONT BLVD
Practice Address - Street 2:UNIT 1
Practice Address - City:MILLSBORO
Practice Address - State:DE
Practice Address - Zip Code:19966-4799
Practice Address - Country:US
Practice Address - Phone:302-297-0700
Practice Address - Fax:302-297-0701
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10000921225100000X
MD18065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000220726Medicaid
DE463716Y0XMedicare PIN