=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922343680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2012
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 W 12TH ST
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68901-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-462-9191
-----------------------------------------------------
Fax | 402-462-9192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1414 W 12TH ST
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68901-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-462-9191
-----------------------------------------------------
Fax | 402-462-9192
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. NATHAN BOLEN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 402-462-9191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------