Healthcare Provider Details

I. General information

NPI: 1184156069
Provider Name (Legal Business Name): MIXAN EYECARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12424 W DODGE RD STE 104
OMAHA NE
68154-2322
US

IV. Provider business mailing address

805 W CENTENNIAL RD
PAPILLION NE
68046-7017
US

V. Phone/Fax

Practice location:
  • Phone: 531-233-5680
  • Fax: 531-215-0937
Mailing address:
  • Phone: 531-233-5680
  • Fax: 531-215-0937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1455
License Number StateNE

VIII. Authorized Official

Name: MARK MIXAN
Title or Position: PRESIDENT
Credential: OD
Phone: 641-373-1951