Provider Demographics
NPI:1144555418
Name:DR CARL V NICHOLSON INC
Entity type:Organization
Organization Name:DR CARL V NICHOLSON INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:626-795-3453
Mailing Address - Street 1:709 E COLORADO BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2125
Mailing Address - Country:US
Mailing Address - Phone:626-795-3453
Mailing Address - Fax:
Practice Address - Street 1:709 E COLORADO BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2125
Practice Address - Country:US
Practice Address - Phone:626-795-3453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10650305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization