Basic Information
| Provider Information | |||||||||
| NPI: | 1265802631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | KEEGAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS, ATC, SPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S LOCUST GROVE RD UNIT O101 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187895704 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 554 N STEELHEAD WAY STE 162 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239747 | ||||||||
| FaxNumber: | 2083239752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 225100000X | 7532 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.