Provider Demographics
NPI:1336309046
Name:NICKERSON OPTICAL
Entity Type:Organization
Organization Name:NICKERSON OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASTER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-725-7741
Mailing Address - Street 1:8 MASON ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-1514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 MASON ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1514
Practice Address - Country:US
Practice Address - Phone:207-725-7741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1209420001Medicare NSC