Provider Demographics
NPI:1992986467
Name:NORTH PLATTE VISION CENTER, LLC
Entity type:Organization
Organization Name:NORTH PLATTE VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BLACKLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-532-1753
Mailing Address - Street 1:402 S DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5423
Mailing Address - Country:US
Mailing Address - Phone:308-532-1753
Mailing Address - Fax:308-532-3480
Practice Address - Street 1:402 S DEWEY ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5423
Practice Address - Country:US
Practice Address - Phone:308-532-1753
Practice Address - Fax:308-532-3480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE953332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE0957230001Medicare NSC