Healthcare Provider Details

I. General information

NPI: 1477595783
Provider Name (Legal Business Name): LARRY LEE NICHOLSON II OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19870 MAIN ST E
HUNTINGDON TN
38344-3927
US

IV. Provider business mailing address

19870 MAIN ST E
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 Number
License Number State

VIII. Authorized Official

Name: LARRY LEE NICHOLSON II OD
Title or Position: OWNER CORPORATION PRESIDENT
Credential: O.D.
Phone: 731-986-4400