Basic Information
| Provider Information | |||||||||
| NPI: | 1417915596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4012 BARBE WOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706052316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513775228 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Practice Location | |||||||||
| Address1: | 8088 HAWKS RD | ||||||||
| Address2: | |||||||||
| City: | LEESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714466649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513775228 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 00023044 | AL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 311032 | LA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1417915596 | 01 | LA | BCBS | OTHER | 1417915596 | 01 | LA | AETNA | OTHER | 1485250 | 05 | LA | MEDICAID |