1316586464 NPI number — ELKHORN RIDGE VISION PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316586464 NPI number — ELKHORN RIDGE VISION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELKHORN RIDGE VISION 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:
VIEWPOINTE VISION-GILES
Provider Other Organization Name Type Code:
3
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:
1316586464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 714
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINVIEW
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68769-0714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-335-7963
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 N 179TH ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68118-3569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-614-4322
Provider Business Practice Location Address Fax Number:
402-614-4475
Provider Enumeration Date:
01/06/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRIST
Authorized Official First Name:
TRISHA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
402-614-4322

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)