Healthcare Provider Details

I. General information

NPI: 1073739470
Provider Name (Legal Business Name): SIDNEY VISION CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PINE ST
SIDNEY NE
69162-2241
US

IV. Provider business mailing address

PO BOX 61
SIDNEY NE
69162-0061
US

V. Phone/Fax

Practice location:
  • Phone: 308-254-4041
  • Fax: 308-254-3718
Mailing address:
  • Phone: 308-254-4041
  • Fax: 308-254-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number892
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number892
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number892
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number892
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number892
License Number StateNE
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number892
License Number StateNE

VIII. Authorized Official

Name: DR. JEFFREY ALAN COOK
Title or Position: PARTNER
Credential: O.D.
Phone: 308-254-4041