Provider Demographics
NPI:1205864980
Name:ALLIANCE VISION SOURCE, P.C.
Entity type:Organization
Organization Name:ALLIANCE VISION SOURCE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:V
Authorized Official - Last Name:FRANKLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPOT
Authorized Official - Phone:308-762-3124
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-0490
Mailing Address - Country:US
Mailing Address - Phone:308-762-3124
Mailing Address - Fax:308-762-7326
Practice Address - Street 1:515 NIOBRARA AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3421
Practice Address - Country:US
Practice Address - Phone:308-762-3124
Practice Address - Fax:308-762-7326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE205248OtherEYEMED VISION
NE10025031600Medicaid
NEDA9238OtherRAILROAD MEDICARE
NE4971810001Medicare NSC
NE099419Medicare PIN
NE205248OtherEYEMED VISION