Provider Demographics
NPI:1700983954
Name:PAUL W. NIENABER, OD, PA
Entity Type:Organization
Organization Name:PAUL W. NIENABER, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:NIENABER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-969-5514
Mailing Address - Street 1:300 BETHANIA RURAL HALL RD
Mailing Address - Street 2:PO BOX 429
Mailing Address - City:RURAL HALL
Mailing Address - State:NC
Mailing Address - Zip Code:27045-9281
Mailing Address - Country:US
Mailing Address - Phone:336-969-5514
Mailing Address - Fax:336-969-5515
Practice Address - Street 1:300 BETHANIA RURAL HALL RD
Practice Address - Street 2:HIGHWAY 65 W
Practice Address - City:RURAL HALL
Practice Address - State:NC
Practice Address - Zip Code:27045-9281
Practice Address - Country:US
Practice Address - Phone:336-969-5514
Practice Address - Fax:336-969-5515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013H8Medicaid
NC5854700001Medicare NSC
NC2308065Medicare PIN