Provider Demographics
NPI:1174572556
Name:NICHOLS OPTICAL INC
Entity type:Organization
Organization Name:NICHOLS OPTICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-941-7788
Mailing Address - Street 1:3200 S AIRPORT RD W
Mailing Address - Street 2:SUITE 146
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8117
Mailing Address - Country:US
Mailing Address - Phone:231-941-7788
Mailing Address - Fax:
Practice Address - Street 1:2368 US 23 S
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-4546
Practice Address - Country:US
Practice Address - Phone:989-356-9096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2009-01-20
Deactivation Date:2008-11-21
Deactivation Code:
Reactivation Date:2009-01-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI862710523Medicaid
MI0249200001Medicare NSC