Provider Demographics
NPI:1730660580
Name:WAKAN PATH, LLC
Entity Type:Organization
Organization Name:WAKAN PATH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:402-210-6129
Mailing Address - Street 1:4913 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-2417
Mailing Address - Country:US
Mailing Address - Phone:402-210-6129
Mailing Address - Fax:
Practice Address - Street 1:5018 AMES AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-2323
Practice Address - Country:US
Practice Address - Phone:402-970-9301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-28
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty