Provider Demographics
NPI:1487899001
Name:ROGER A KLASSEN INC
Entity type:Organization
Organization Name:ROGER A KLASSEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-597-8990
Mailing Address - Street 1:8504 S 100TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3072
Mailing Address - Country:US
Mailing Address - Phone:402-597-8990
Mailing Address - Fax:
Practice Address - Street 1:8525 S 71ST PLZ
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68133-2100
Practice Address - Country:US
Practice Address - Phone:402-597-8990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1055152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025067700Medicaid
NE10025067700Medicaid