Healthcare Provider Details

I. General information

NPI: 1588665384
Provider Name (Legal Business Name): ROGER A KLASSEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

7904 S 83RD ST
LAVISTA NE
68128-2774
US

IV. Provider business mailing address

8504 S 100TH ST
LAVISTA NE
68128-3072
US

V. Phone/Fax

Practice location:
  • Phone: 402-597-8990
  • Fax: 402-597-8992
Mailing address:
  • Phone: 402-597-8990
  • Fax: 402-597-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1055
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14293
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2153
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002700
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: