Provider Demographics
NPI:1477608610
Name:ALLIANCE VISION SOURCE, P.C.
Entity Type:Organization
Organization Name:ALLIANCE VISION SOURCE, P.C.
Other - Org Name:BRIDGEPORT VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATION SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-262-1252
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-0354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336
Practice Address - Country:US
Practice Address - Phone:308-262-1252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA9238Medicare PIN
NE099419Medicare PIN
NE4971810002Medicare NSC