Provider Demographics
NPI:1730387309
Name:SALLER, NICHOLAS J (MPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:SALLER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132B SUNSET COURT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-2429
Mailing Address - Country:US
Mailing Address - Phone:803-796-5116
Mailing Address - Fax:803-796-5131
Practice Address - Street 1:132B SUNSET COURT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-2429
Practice Address - Country:US
Practice Address - Phone:803-796-5116
Practice Address - Fax:803-796-5131
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC49980743OtherBLUECROSS BLUESHIELD OF SOUTH CAROLINA
SCP00470381OtherMEDICARE RAILROAD
SC8644Medicare PIN