Provider Demographics
NPI:1598714008
Name:LYNDON GRAVES, P.C.
Entity Type:Organization
Organization Name:LYNDON GRAVES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNDON
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-898-3232
Mailing Address - Street 1:9239 W CENTER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-1933
Mailing Address - Country:US
Mailing Address - Phone:402-898-3232
Mailing Address - Fax:402-898-3234
Practice Address - Street 1:9239 W CENTER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1933
Practice Address - Country:US
Practice Address - Phone:402-898-3232
Practice Address - Fax:402-898-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0432161Medicaid
OKG20027930AMedicaid
WA2029544Medicaid
LA1151289Medicaid
KY7100151470Medicaid
VADP5289Medicare PIN
OK300522068Medicare PIN
WA2029544Medicaid
KY7100151470Medicaid
IA0432161Medicaid
VAC10696Medicare PIN
WAG8807707Medicare PIN
DC5533Medicare PIN
DF1828Medicare PIN
KY01436Medicare PIN
WAG8805237Medicare PIN
IAI11066Medicare ID - Type UnspecifiedMEDICARE PART B GROUP NUM
DC156381Medicare PIN