Healthcare Provider Details

I. General information

NPI: 1205886736
Provider Name (Legal Business Name): LYNDON GRAVES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9239 W CENTER RD SUITE 103
OMAHA NE
68124-1900
US

IV. Provider business mailing address

9239 W CENTER RD STE 103
OMAHA NE
68124-1900
US

V. Phone/Fax

Practice location:
  • Phone: 402-898-3232
  • Fax: 402-898-3234
Mailing address:
  • Phone: 402-898-3232
  • Fax: 402-898-3234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0601800388
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number998
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15201890
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2277
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2967T
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003880
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5659180-9934
License Number StateUT
# 8
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1387
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: