Provider Demographics
NPI:1679388060
Name:FORMICA, NICHOLAS (PTA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:FORMICA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 S KOLMAR AVE
Mailing Address - Street 2:
Mailing Address - City:HOMETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:60456-1027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4061 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2611
Practice Address - Country:US
Practice Address - Phone:630-469-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160010305261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy