Provider Demographics
NPI:1568643476
Name:NICHOLS, LARISSA MARIE (CERTIFIED OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CERTIFIED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6900
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-0100
Mailing Address - Country:US
Mailing Address - Phone:310-214-0811
Mailing Address - Fax:310-793-4658
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:310-214-0811
Practice Address - Fax:310-793-4658
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA173420156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13687VMedicare PIN