Basic Information
| Provider Information | |||||||||
| NPI: | 1205058310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKLEBERRY | ||||||||
| FirstName: | BARON | ||||||||
| MiddleName: | TYRONE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7410 BLANCO RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782164363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004046050 | ||||||||
| FaxNumber: | 2104774956 | ||||||||
| Practice Location | |||||||||
| Address1: | 7410 BLANCO RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782164363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004046050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 9283 | TX | Y | Chiropractic Providers | Chiropractor | 111NR0400X | 9283 | TX | N | Chiropractic Providers | Chiropractor | Rehabilitation | 111NS0005X | 9283 | TX | N | Chiropractic Providers | Chiropractor | Sports Physician |
No ID Information.