Healthcare Provider Details

I. General information

NPI: 1053313338
Provider Name (Legal Business Name): LARRY LEE NICHOLSON II O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19870 MAIN E ST
HUNTINGDON TN
38344-3927
US

IV. Provider business mailing address

19870 MAIN E ST
HUNTINGDON TN
38344-3927
US

V. Phone/Fax

Practice location:
  • Phone: 731-986-4400
  • Fax: 731-986-7981
Mailing address:
  • Phone: 731-986-4400
  • Fax: 731-986-7981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODT2544
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: