1932190527 NPI number — PRAIRIE EYECARE CENTER PC

Table of content: (NPI 1932190527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932190527 NPI number — PRAIRIE EYECARE CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE EYECARE CENTER PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRAIRIE EYECARE CENTER LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932190527
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 506
Provider Second Line Business Mailing Address:
408 S 8TH AVE
Provider Business Mailing Address City Name:
BROKEN BOW
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68822-0506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-872-2291
Provider Business Mailing Address Fax Number:
308-872-3122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 S 8TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN BOW
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68822-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-872-2291
Provider Business Practice Location Address Fax Number:
308-872-3122
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SANGER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
308-872-2291

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47077269013 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: C04190 . This is a "PALMETTO GBA RAILROAD MED" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: DN0887 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025628100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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