Basic Information
| Provider Information | |||||||||
| NPI: | 1760653778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUTH NICOLAS, OD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 570 RIVERSTONE WAY | ||||||||
| Address2: | STE 3 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074794700 | ||||||||
| FaxNumber: | 9074575596 | ||||||||
| Practice Location | |||||||||
| Address1: | 570 RIVERSTONE WAY | ||||||||
| Address2: | STE 3 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074794700 | ||||||||
| FaxNumber: | 9074575596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | NICOLAS | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9074794700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | A125 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | OD01251 | 05 | AK | MEDICAID |