Basic Information
| Provider Information | |||||||||
| NPI: | 1740385616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLUCKHOHN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | SANFACON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANFACON | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 BROOKFIELD PKWY STE 500A | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296075795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645490017 | ||||||||
| FaxNumber: | 8645285701 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 BALLYHOO CT | ||||||||
| Address2: | |||||||||
| City: | GREER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296514914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649075324 | ||||||||
| FaxNumber: | 8336154258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3529 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | TH1787 | 05 | SC | MEDICAID |