Provider Demographics
NPI:1003909789
Name:OREGON TRAIL EYE SURGERY CENTER, INC
Entity Type:Organization
Organization Name:OREGON TRAIL EYE SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-635-3911
Mailing Address - Street 1:329 WEST 40TH STREET
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4634
Mailing Address - Country:US
Mailing Address - Phone:308-635-3911
Mailing Address - Fax:308-635-3130
Practice Address - Street 1:329 WEST 40TH STREET
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4634
Practice Address - Country:US
Practice Address - Phone:308-635-3911
Practice Address - Fax:308-635-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEASC039261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025073600Medicaid
NE5490380Medicaid
NE99498Medicare ID - Type Unspecified