Provider Demographics
NPI:1073739470
Name:SIDNEY VISION CLINIC LLC
Entity Type:Organization
Organization Name:SIDNEY VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-254-4041
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-0061
Mailing Address - Country:US
Mailing Address - Phone:308-254-4041
Mailing Address - Fax:308-254-3718
Practice Address - Street 1:900 PINE ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-2241
Practice Address - Country:US
Practice Address - Phone:308-254-4041
Practice Address - Fax:308-254-3718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE892152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37094OtherBCBS PROVIDER NUMBER
NE10025341000Medicaid
NE410025992OtherUHC RR MEDICARE PROVIDER
NE245327OtherMIDLANDS CHOICE PROV NMBR
NE10025341000Medicaid