Provider Demographics
NPI:1386821981
Name:PROFESSIONAL EYECARE ASSOCIATES AND OPTICAL PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE ASSOCIATES AND OPTICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:731-415-9368
Mailing Address - Street 1:2118 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-3054
Mailing Address - Country:US
Mailing Address - Phone:731-784-1973
Mailing Address - Fax:731-784-9545
Practice Address - Street 1:2118 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3054
Practice Address - Country:US
Practice Address - Phone:731-784-1973
Practice Address - Fax:731-784-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT2544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6317180001Medicare NSC