=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477805562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. NICHOLAS GRAHAM AND ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2012
-----------------------------------------------------
Last Update Date | 10/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 SAM NEWELL RD SUITE 203
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28105-7593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-245-0427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2085
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28106-2085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-245-0427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NICHOLAS D GRAHAM
-----------------------------------------------------
Credential | O.D., M.S.
-----------------------------------------------------
Telephone | 843-245-0427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1599
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2222
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------