Healthcare Provider Details

I. General information

NPI: 1649697491
Provider Name (Legal Business Name): NORTHEAST EYECARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W DECATUR ST
WEST POINT NE
68788-1407
US

IV. Provider business mailing address

101 W DECATUR ST
WEST POINT NE
68788-1407
US

V. Phone/Fax

Practice location:
  • Phone: 402-372-3266
  • Fax: 402-372-5736
Mailing address:
  • Phone: 402-372-3266
  • Fax: 402-372-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1396
License Number StateNE

VIII. Authorized Official

Name: DR. BRANDON RIDDER
Title or Position: OWNER
Credential: OD
Phone: 402-372-3266