Healthcare Provider Details

I. General information

NPI: 1942226865
Provider Name (Legal Business Name): ROBERT CRAIG DIETRICH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 NIOBRARA AVE
ALLIANCE NE
69301-3421
US

IV. Provider business mailing address

515 NIOBRARA AVE
ALLIANCE NE
69301-3421
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 Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number817
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: