Provider Demographics
NPI:1972533354
Name:CHADRON VISION CENTER, INC.
Entity type:Organization
Organization Name:CHADRON VISION CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHETLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-282-0820
Mailing Address - Street 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:NE
Mailing Address - Zip Code:69343-1524
Mailing Address - Country:US
Mailing Address - Phone:308-282-0820
Mailing Address - Fax:308-282-0833
Practice Address - Street 1:112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:NE
Practice Address - Zip Code:69343-1524
Practice Address - Country:US
Practice Address - Phone:308-282-0820
Practice Address - Fax:308-282-0833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHADRON VISION CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-03
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE507800115Medicaid
SD9200912Medicaid
NE507303268Medicaid
SD9200330Medicaid
SD9202142Medicaid
NE504082854Medicaid
NE508922022Medicaid
SD9203682Medicaid
NE507303268Medicaid
NE265050Medicare PIN
NE280911Medicare PIN
NE507800115Medicaid
SD9202142Medicaid
0324130003Medicare NSC
NE087845Medicare PIN
NEV11678Medicare UPIN
NEE52883Medicare UPIN