Provider Demographics
NPI:1306019062
Name:OPTICAL GALLERY, LLC
Entity Type:Organization
Organization Name:OPTICAL GALLERY, LLC
Other - Org Name:OPTICAL GALLERY
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTOWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:THILGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-488-3106
Mailing Address - Street 1:3923 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-4318
Mailing Address - Country:US
Mailing Address - Phone:402-488-3106
Mailing Address - Fax:402-488-3329
Practice Address - Street 1:3923 S 48TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-4318
Practice Address - Country:US
Practice Address - Phone:402-488-3106
Practice Address - Fax:402-488-3329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEDN6715OtherMEDICARE RAILROAD CARRIER
NE10025614200Medicaid
NE10025614200Medicaid
NENA1068Medicare PIN