Provider Demographics
NPI:1891881132
Name:CENTRACCHIO, NICOLE A (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:CENTRACCHIO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 PLEASANT ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-3005
Mailing Address - Country:US
Mailing Address - Phone:508-678-2718
Mailing Address - Fax:508-646-0333
Practice Address - Street 1:289 PLEASANT ST
Practice Address - Street 2:SUITE 201
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-3005
Practice Address - Country:US
Practice Address - Phone:508-678-2718
Practice Address - Fax:508-646-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4583152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17652Medicare PIN