Provider Demographics
NPI:1972552362
Name:NICHOLS OPTICAL INC
Entity Type:Organization
Organization Name:NICHOLS OPTICAL INC
Other - Org Name:PEARLE VISION 8808
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-941-7788
Mailing Address - Street 1:3200 S AIRPORT RD W
Mailing Address - Street 2:SUITE 146
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8117
Mailing Address - Country:US
Mailing Address - Phone:231-941-7788
Mailing Address - Fax:
Practice Address - Street 1:6800 EASTMAN AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-7810
Practice Address - Country:US
Practice Address - Phone:989-839-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI863265117Medicaid
MI863265117Medicaid