Provider Demographics
NPI:1649697491
Name:NORTHEAST EYECARE PC
Entity type:Organization
Organization Name:NORTHEAST EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-372-3266
Mailing Address - Street 1:101 W DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NE
Mailing Address - Zip Code:68788-1407
Mailing Address - Country:US
Mailing Address - Phone:402-372-3266
Mailing Address - Fax:402-372-5736
Practice Address - Street 1:101 W DECATUR ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NE
Practice Address - Zip Code:68788-1407
Practice Address - Country:US
Practice Address - Phone:402-372-3266
Practice Address - Fax:402-372-5736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100264775-00Medicaid
NE100264106-00Medicaid
NE25136OtherCOVENTRY
NE8422OtherMIDLANDS CHOICE
NE7748OtherBLUE CROSS
NE25136OtherCOVENTRY
NE100264106-00Medicaid