Provider Demographics
NPI:1750430567
Name:J LARRY PRITCHETT O D P C
Entity type:Organization
Organization Name:J LARRY PRITCHETT O D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:PRITCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-995-2920
Mailing Address - Street 1:279 PEARSON DR SW
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:GA
Mailing Address - Zip Code:39842-1914
Mailing Address - Country:US
Mailing Address - Phone:229-995-2920
Mailing Address - Fax:229-995-5034
Practice Address - Street 1:162 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1841
Practice Address - Country:US
Practice Address - Phone:229-336-8991
Practice Address - Fax:229-336-0141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J LARRY PRITCHETT O D P C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000689332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
52103165 001OtherBCBSGA
GA000004199BMedicaid
GA000004199BMedicaid
0143490002Medicare NSC
511G700250Medicare PIN