Provider Demographics
NPI:1972671881
Name:EYECARE ASSOCIATES OF COLUMBUS PC
Entity Type:Organization
Organization Name:EYECARE ASSOCIATES OF COLUMBUS PC
Other - Org Name:SUBCHAPTER S CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MALICKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-564-0545
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68602-1248
Mailing Address - Country:US
Mailing Address - Phone:402-564-0545
Mailing Address - Fax:402-564-0078
Practice Address - Street 1:1371 29TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-4926
Practice Address - Country:US
Practice Address - Phone:402-564-0545
Practice Address - Fax:402-564-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE801152W00000X
NE1069152W00000X
NE1091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06952OtherBCBS
NEN001920OtherCHAMPUS
NE06731OtherBCBS
CH1483OtherRAILROAD MEDICARE
NE36395OtherBCBS
NE06952OtherBCBS
NE06731OtherBCBS
094006Medicare ID - Type Unspecified
U57090Medicare UPIN
T40245Medicare UPIN
NE266987Medicare ID - Type Unspecified
NE=========00Medicaid
NE099084Medicare ID - Type Unspecified