Professional Provider Company, LLC

Primary specialty

OptometristTaxonomy code 152W00000X

Legal business name

PROFESSIONAL PROVIDER COMPANY, LLC

Practice address

10826 Old Mill Rd Ste 101
Omaha, NE 68154-2660

Phone

(888) 840-3032

Fax

(888) 840-8937

NPI assigned

Oct 20, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lyndon J Graves, OD

Title

Owner

Phone

(888) 840-3032

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1255996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1521244800000",
    "number": "1881920288",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10826 OLD MILL RD STE 101",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681542660",
            "telephone_number": "888-840-3032",
            "fax_number": "888-840-8937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10826 OLD MILL RD STE 101",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681542660",
            "telephone_number": "888-840-3032",
            "fax_number": "888-840-8937"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10826 Old Mill Rd Ste 101",
            "address_purpose": "LOCATION",
            "city": "Omaha",
            "state": "NE",
            "postal_code": "681542660",
            "country_code": "US",
            "telephone_number": "888-840-3032",
            "fax_number": "888-840-8937",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROFESSIONAL PROVIDER COMPANY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-10-20",
        "last_updated": "2018-03-17",
        "status": "A",
        "authorized_official_last_name": "GRAVES",
        "authorized_official_first_name": "LYNDON",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "888-840-3032",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1881920288",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Omaha, NE
• Optometrist in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.