Provider Demographics
NPI:1366558579
Name:REFVEM, NICHOLAS L (ATC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:L
Last Name:REFVEM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 TRUMAN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9540
Mailing Address - Country:US
Mailing Address - Phone:208-596-2998
Mailing Address - Fax:
Practice Address - Street 1:124 KIBBIE ACTIVITY CTR
Practice Address - Street 2:BOX 442302
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-2302
Practice Address - Country:US
Practice Address - Phone:208-885-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-2182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer