Provider Demographics
NPI:1376716555
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:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-223-2950
Mailing Address - Street 1:2205 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-1264
Mailing Address - Country:US
Mailing Address - Phone:402-223-2950
Mailing Address - Fax:402-223-5320
Practice Address - Street 1:2205 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-1264
Practice Address - Country:US
Practice Address - Phone:402-223-2950
Practice Address - Fax:402-223-5320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025614300Medicaid