Provider Demographics
NPI:1952544215
Name:OPTICAL GALLERY LLC
Entity Type:Organization
Organization Name:OPTICAL GALLERY LLC
Other - Org Name:OPTICAL GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERL;Y
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-470-0074
Mailing Address - Street 1:1550 S CODDINGTON AVE
Mailing Address - Street 2:SUITE V
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68522-4402
Mailing Address - Country:US
Mailing Address - Phone:402-470-0074
Mailing Address - Fax:402-261-5855
Practice Address - Street 1:1550 S CODDINGTON AVE
Practice Address - Street 2:SUITE V
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-4402
Practice Address - Country:US
Practice Address - Phone:402-470-0074
Practice Address - Fax:402-261-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025701100Medicaid
NE10025701100Medicaid
NE6183090003Medicare NSC