Provider Demographics
NPI:1649310350
Name:WISE EYECARE LLC
Entity type:Organization
Organization Name:WISE EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-421-7773
Mailing Address - Street 1:1501 PINE LAKE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-3692
Mailing Address - Country:US
Mailing Address - Phone:402-421-7773
Mailing Address - Fax:402-421-7859
Practice Address - Street 1:1501 PINE LAKE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-3692
Practice Address - Country:US
Practice Address - Phone:402-421-7773
Practice Address - Fax:402-421-7859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1124152WC0802X, 152WP0200X, 152WV0400X, 152W00000X
NE1123152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099349Medicare ID - Type Unspecified