Provider Demographics
NPI:1386691137
Name:IIII, PC
Entity Type:Organization
Organization Name:IIII, PC
Other - Org Name:MID AMERICA VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOB
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:402-362-3313
Mailing Address - Street 1:436 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:NE
Mailing Address - Zip Code:68370-1526
Mailing Address - Country:US
Mailing Address - Phone:402-768-6651
Mailing Address - Fax:402-768-6657
Practice Address - Street 1:436 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:NE
Practice Address - Zip Code:68370-1526
Practice Address - Country:US
Practice Address - Phone:402-768-6651
Practice Address - Fax:402-768-6657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE 931152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE096639Medicare PIN
NE1181760001Medicare NSC