Provider Demographics
NPI:1295986370
Name:PRAIRIE EYECARE CENTER LLC
Entity type:Organization
Organization Name:PRAIRIE EYECARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SANGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-872-2291
Mailing Address - Street 1:408 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-2009
Mailing Address - Country:US
Mailing Address - Phone:308-872-2291
Mailing Address - Fax:308-872-3122
Practice Address - Street 1:408 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-2009
Practice Address - Country:US
Practice Address - Phone:308-872-2291
Practice Address - Fax:308-872-3122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE EYECARE CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
098011OtherMEDICARE PTAN
410011100OtherRR MEDICARE
0723900001OtherDMERC