Healthcare Provider Details

I. General information

NPI: 1770852196
Provider Name (Legal Business Name): PROFESSIONAL PROVIDER ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10826 OLD MILL RD STE 101
OMAHA NE
68154-2660
US

IV. Provider business mailing address

10826 OLD MILL RD STE 101
OMAHA NE
68154-2660
US

V. Phone/Fax

Practice location:
  • Phone: 402-898-3232
  • Fax: 402-898-3234
Mailing address:
  • Phone: 888-840-3032
  • Fax: 888-270-3811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number01891
License Number StateIA

VIII. Authorized Official

Name: JOHN ROSENBAUM
Title or Position: CCO
Credential:
Phone: 913-647-7926