Healthcare Provider Details

I. General information

NPI: 1649310350
Provider Name (Legal Business Name): WISE EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 PINE LAKE RD SUITE 1
LINCOLN NE
68512-3692
US

IV. Provider business mailing address

1501 PINE LAKE RD SUITE 1
LINCOLN NE
68512-3692
US

V. Phone/Fax

Practice location:
  • Phone: 402-421-7773
  • Fax: 402-421-7859
Mailing address:
  • Phone: 402-421-7773
  • Fax: 402-421-7859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1124
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1124
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1124
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number1123
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1124
License Number StateNE

VIII. Authorized Official

Name: ELLEN LAST
Title or Position: OPTICIAN
Credential:
Phone: 402-421-7773