Provider Demographics
NPI:1639120173
Name:SENIOR MEDICAL SPECIALTIES, INC.
Entity Type:Organization
Organization Name:SENIOR MEDICAL SPECIALTIES, INC.
Other - Org Name:SENIOR MEDICAL SPECIALTIES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-840-3032
Mailing Address - Street 1:PO BOX 30152
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-1252
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:68124-1900
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:2006-05-12
Last Update Date:2009-07-08
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
NE=========00Medicaid
NE=========00Medicaid
CJ8814Medicare PIN