Individual
CHARLES RICHARD NICHOLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
11513 W FAIRVIEW AVE, SUITE 106, BOISE, ID 83713-7886
(208) 322-8439
(208) 322-8433
Mailing address
11513 W FAIRVIEW AVE, SUITE 106, BOISE, ID 83713-7886
(208) 322-8439
(208) 322-8433
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
ODP-100134
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010162496
REGENCE BLUE SHIELD
ID
01
—
1590015
MEDICARE PTAN
ID
Enumeration date
07/20/2006
Last updated
01/26/2009
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