Basic Information
| Provider Information | |||||||||
| NPI: | 1740386606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OMAHA EYE & LASER INSTITUTE, INC. | ||||||||
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| OtherOrganizationName: | LINCOLN EYE & LASER INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11606 NICHOLAS STREET, | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681544486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028983818 | ||||||||
| FaxNumber: | 4024938341 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 FALLBROOK BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685214637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028983818 | ||||||||
| FaxNumber: | 4024938341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | LIU | ||||||||
| AuthorizedOfficialFirstName: | SAO | ||||||||
| AuthorizedOfficialMiddleName: | JANG | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4024932020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OMAHA EYE & LASER INSTITUTE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CH8149 | 01 | NE | RR MEDICARE | OTHER |