Provider Demographics
NPI:1558905588
Name:RYAN NICHOLAS OD LLC
Entity Type:Organization
Organization Name:RYAN NICHOLAS OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-542-5208
Mailing Address - Street 1:5268 BASKIN ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6920
Mailing Address - Country:US
Mailing Address - Phone:909-542-5208
Mailing Address - Fax:
Practice Address - Street 1:4200 CONROY RD # B166
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-2400
Practice Address - Country:US
Practice Address - Phone:407-473-3539
Practice Address - Fax:407-796-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty