Basic Information
| Provider Information | |||||||||
| NPI: | 1184811804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOARA | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 441146 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301609522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784033632 | ||||||||
| FaxNumber: | 6785676737 | ||||||||
| Practice Location | |||||||||
| Address1: | 11808 KINGSTON PIKE | ||||||||
| Address2: | SUITE 185 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379343803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656752820 | ||||||||
| FaxNumber: | 8656752821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 7915 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.