Provider Demographics
NPI:1134252711
Name:ILLUSIONS EYEWEAR LLC
Entity type:Organization
Organization Name:ILLUSIONS EYEWEAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:402-451-1717
Mailing Address - Street 1:8616 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-1808
Mailing Address - Country:US
Mailing Address - Phone:402-451-1717
Mailing Address - Fax:402-451-3469
Practice Address - Street 1:8616 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-1808
Practice Address - Country:US
Practice Address - Phone:402-451-1717
Practice Address - Fax:402-451-3469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA1057OtherPTAN
NE10025369100Medicaid
NE017542Medicaid