Provider Demographics
NPI:1659464337
Name:OREGON TRAIL EYE CENTER, PC
Entity Type:Organization
Organization Name:OREGON TRAIL EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-635-3911
Mailing Address - Street 1:329 WEST 40TH STREET
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4634
Mailing Address - Country:US
Mailing Address - Phone:308-635-9311
Mailing Address - Fax:308-635-3130
Practice Address - Street 1:329 WEST 40TH STREET
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4634
Practice Address - Country:US
Practice Address - Phone:308-635-9311
Practice Address - Fax:308-635-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025252500Medicaid
NE99519Medicare ID - Type Unspecified