1770660839 NPI number — FAMILY VISION CENTER, PC

Table of content: (NPI 1770660839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770660839 NPI number — FAMILY VISION CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY VISION 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:
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:
1770660839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1024 AVENUE E
Provider Second Line Business Mailing Address:
P.O. BOX 367
Provider Business Mailing Address City Name:
WISNER
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68791-2248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-529-3558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1024 AVENUE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WISNER
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68791-2248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-529-3558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAURITZEN
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-529-3558

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  767 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , with the licence number: 767 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 25136 . This is a "WISNER COVENTRY PAYOR ID" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 8422 . This is a "WISNER MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 7748 . This is a "WISNER BLUE CROSS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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