1174572556 NPI number — NICHOLS OPTICAL INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174572556 NPI number — NICHOLS OPTICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICHOLS OPTICAL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174572556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/21/2008
NPI Reactivation Date:
01/20/2009

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 S AIRPORT RD W
Provider Second Line Business Mailing Address:
SUITE 146
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-8117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-941-7788
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2368 US 23 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPENA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49707-4546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-356-9096
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIRTH
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
231-941-7788

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 862710523 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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