=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326317082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALBAR VISION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2011
-----------------------------------------------------
Last Update Date | 12/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 O ST STE A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68510-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-475-9113
-----------------------------------------------------
Fax | 402-475-8084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 O ST STE A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68510-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-475-9113
-----------------------------------------------------
Fax | 402-475-8084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MISS JAIMI LEE ROSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-475-9113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0763
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------