Organization
PROVISION EYE CARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DANIEL MARK JACKSON O.D. (OWNER)
(402) 991-3131
Entity
Organization
Contact information
Practice address
713 N 114TH ST, OMAHA, NE 68154-1515
(402) 991-3131
Mailing address
713 N 114TH ST, OMAHA, NE 68154-1515
(402) 991-3131
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
960
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10025388400
—
NE
01
—
37154
BCBS
NE
01
—
904415
SHARE ADVANTAGE
NE
01
—
P00393695
RR MEDICARE
NE
Enumeration date
06/14/2016
Last updated
07/06/2016
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