1073739470 NPI number — SIDNEY VISION CLINIC LLC

Table of content: (NPI 1073739470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073739470 NPI number — SIDNEY VISION CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIDNEY VISION CLINIC LLC
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:
Provider Other Organization Name Type Code:
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:
1073739470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 61
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIDNEY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69162-0061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-254-4041
Provider Business Mailing Address Fax Number:
308-254-3718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIDNEY
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69162-2241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-254-4041
Provider Business Practice Location Address Fax Number:
308-254-3718
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
308-254-4041

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  892 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: 892 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WS0006X , with the licence number: 892 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 892 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WX0102X , with the licence number: 892 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 892 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37094 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025341000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410025992 . This is a "UHC RR MEDICARE PROVIDER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 245327 . This is a "MIDLANDS CHOICE PROV NMBR" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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