Provider Demographics
NPI:1477805562
Name:DR. NICHOLAS GRAHAM AND ASSOCIATES
Entity Type:Organization
Organization Name:DR. NICHOLAS GRAHAM AND ASSOCIATES
Other - Org Name:DIVERSIFIED EYECARE ASSOCIATES OD, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MS
Authorized Official - Phone:843-245-0427
Mailing Address - Street 1:PO BOX 2085
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28106-2085
Mailing Address - Country:US
Mailing Address - Phone:843-245-0427
Mailing Address - Fax:
Practice Address - Street 1:855 SAM NEWELL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-7593
Practice Address - Country:US
Practice Address - Phone:843-245-0427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2222152W00000X
SC1599152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty