Healthcare Provider Details

I. General information

NPI: 1881920288
Provider Name (Legal Business Name): PROFESSIONAL PROVIDER COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 03/17/2018
Certification Date:
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: 888-840-3032
  • Fax: 888-840-8937
Mailing address:
  • Phone: 888-840-3032
  • Fax: 888-840-8937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: LYNDON J GRAVES
Title or Position: OWNER
Credential: OD
Phone: 888-840-3032