=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154094316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANT FAMILY EYECARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2021
-----------------------------------------------------
Last Update Date | 07/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20330 VETERANS DR STE 4
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68022-6929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-885-7695
-----------------------------------------------------
Fax | 402-884-2885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 N 181ST AVE
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68022-3883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-380-3558
-----------------------------------------------------
Fax | 402-884-2885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | GINNY L AHRENS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 402-380-3558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------