Healthcare Provider Details

I. General information

NPI: 1205864980
Provider Name (Legal Business Name): ALLIANCE VISION SOURCE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 NIOBRARA AVE
ALLIANCE NE
69301-3421
US

IV. Provider business mailing address

PO BOX 490
ALLIANCE NE
69301-0490
US

V. Phone/Fax

Practice location:
  • Phone: 308-762-3124
  • Fax: 308-762-7326
Mailing address:
  • Phone: 308-762-3124
  • Fax: 308-762-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMARA V FRANKLLIN
Title or Position: OFFICE ADMINISTRATOR
Credential: CPOT
Phone: 308-762-3124