Healthcare Provider Details

I. General information

NPI: 1063501732
Provider Name (Legal Business Name): OGALLALA EYECARE,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W EMERSON ST
HOLYOKE CO
80734-1431
US

IV. Provider business mailing address

PO BOX 568
OGALLALA NE
69153-0568
US

V. Phone/Fax

Practice location:
  • Phone: 970-854-4030
  • Fax:
Mailing address:
  • Phone: 308-284-4394
  • Fax: 308-284-4123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1765
License Number StateCO

VIII. Authorized Official

Name: DR. JOHN J PALOUCEK
Title or Position: OWNER
Credential: OD
Phone: 308-284-4394