1972533354 NPI number — CHADRON VISION CENTER, INC.

Table of content: (NPI 1972533354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972533354 NPI number — CHADRON VISION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHADRON VISION CENTER, INC.
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:
GORDON VISION CENTER
Provider Other Organization Name Type Code:
5
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:
1972533354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GORDON
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69343-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-282-0820
Provider Business Mailing Address Fax Number:
308-282-0833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORDON
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69343-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-282-0820
Provider Business Practice Location Address Fax Number:
308-282-0833
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHETLER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER / OPTOMETRIST
Authorized Official Telephone Number:
308-282-0820

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: 507800115 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9200912 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 507303268 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9200330 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9202142 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 504082854 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 508922022 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9203682 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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