Provider Demographics
NPI:1881920288
Name:PROFESSIONAL PROVIDER COMPANY, LLC
Entity type:Organization
Organization Name:PROFESSIONAL PROVIDER COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:888-840-3032
Mailing Address - Street 1:10826 OLD MILL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2660
Mailing Address - Country:US
Mailing Address - Phone:888-840-3032
Mailing Address - Fax:888-840-8937
Practice Address - Street 1:10826 OLD MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2660
Practice Address - Country:US
Practice Address - Phone:888-840-3032
Practice Address - Fax:888-840-8937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1881920288Medicaid
WAG8888487Medicare PIN
ORR159203Medicare PIN
WAG8888486Medicare PIN
OR1881920288Medicaid