Provider Demographics
NPI:1265802631
Name:NICHOLS, KEEGAN (MS, ATC, SPT)
Entity type:Individual
Prefix:MR
First Name:KEEGAN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MS, ATC, SPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S LOCUST GROVE RD UNIT O101
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6389
Mailing Address - Country:US
Mailing Address - Phone:618-789-5704
Mailing Address - Fax:
Practice Address - Street 1:554 N STEELHEAD WAY STE 162
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8388
Practice Address - Country:US
Practice Address - Phone:208-323-9747
Practice Address - Fax:208-323-9752
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ID7532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program