1912564212 NPI number — VISION SPECIALISTS OF OMAHA LLC

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 1912564212 NPI number — VISION SPECIALISTS OF OMAHA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION SPECIALISTS OF OMAHA 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:
1912564212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2514 W BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-322-3097
Provider Business Mailing Address Fax Number:
712-322-4130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3606 N 156TH STREET
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-205-0754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CHEATHAM
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
712-332-3097

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)





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