Healthcare Provider Details

I. General information

NPI: 1750430567
Provider Name (Legal Business Name): J LARRY PRITCHETT O D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 E BROAD ST
CAMILLA GA
31730-1841
US

IV. Provider business mailing address

279 PEARSON DR SW
DAWSON GA
39842-1914
US

V. Phone/Fax

Practice location:
  • Phone: 229-336-8991
  • Fax: 229-336-0141
Mailing address:
  • Phone: 229-995-2920
  • Fax: 229-995-5034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT000689
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOPT000689
License Number StateGA

VIII. Authorized Official

Name: JAMES LARRY PRITCHETT
Title or Position: CEO
Credential: O.D.
Phone: 229-995-2920