Provider Demographics
NPI:1477595783
Name:LARRY LEE NICHOLSON II OD
Entity Type:Organization
Organization Name:LARRY LEE NICHOLSON II OD
Other - Org Name:HUNTINGDON EYE CARE, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER CORPORATION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NICHOLSON II OD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:731-986-4400
Mailing Address - Street 1:19870 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-3927
Mailing Address - Country:US
Mailing Address - Phone:731-986-4400
Mailing Address - Fax:731-986-7981
Practice Address - Street 1:19870 MAIN ST E
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-3927
Practice Address - Country:US
Practice Address - Phone:731-986-4400
Practice Address - Fax:731-986-7981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDB9347OtherRAILROAD MEDICARE
TN3946177OtherMEDICARE INDIVIUAL
TN0381350001Medicare NSC
TN3726259Medicare ID - Type Unspecified