Provider Demographics
NPI:1326559725
Name:VISION SPECIALISTS OF CLOCKTOWER VILLAGE, LLC
Entity Type:Organization
Organization Name:VISION SPECIALISTS OF CLOCKTOWER VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-322-3097
Mailing Address - Street 1:625 N 98TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2342
Mailing Address - Country:US
Mailing Address - Phone:712-322-3097
Mailing Address - Fax:712-322-4130
Practice Address - Street 1:625 N 98TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2342
Practice Address - Country:US
Practice Address - Phone:402-397-0497
Practice Address - Fax:402-397-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty