Optic Gallery Blue Diamond Inc

Primary specialty

OptometristTaxonomy code 152W00000X

License

820 Issued in NV

Legal business name

OPTIC GALLERY BLUE DIAMOND INC

Doing business as

Optic Gallery

Practice address

4860 Blue Diamond Rd Ste 120
Las Vegas, NV 89139-7676

Phone

(702) 710-3937

NPI assigned

Dec 14, 2017

Last updated

Dec 14, 2017By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Elizabeth Peguese, ODNPI 1740689975

Title

Optometrist

Phone

(702) 710-3937

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Optic Gallery Doing business as

Medicare fee-for-service enrollment

Enrolled in NV

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Elizabeth Peguese, OD

  • Optometrist
  • Houston, TX
  • NPI 1740689975

  NV

  Medicare reassignment NPD Authorized official
• Alesha L Johnson

  • Optometrist
  • Las Vegas, NV
  • NPI 1447934146
  NPD (past)

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

{
    "created_epoch": "1513209600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1513209600000",
    "number": "1972019867",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4860 BLUE DIAMOND RD STE 120",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891397676",
            "telephone_number": "702-710-3937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4860 BLUE DIAMOND RD STE 120",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891397676",
            "telephone_number": "702-710-3937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OPTIC GALLERY BLUE DIAMOND INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-12-14",
        "last_updated": "2017-12-14",
        "status": "A",
        "authorized_official_last_name": "PEGUESE",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_title_or_position": "OPTOMETRIST",
        "authorized_official_telephone_number": "702-710-3937",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "NV",
            "license": "820",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1740689975",
            "state": "NV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Optic Gallery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Optic Gallery Centennial Inc (optic gallery)
• Optic Gallery DTS LLC (Optic Gallery)
• Optic Gallery Hualapai LLC
• Optic Gallery Nellis LLC (Optic Gallery Nellis)

• Optometrist in Las Vegas, NV
• Providers in Las Vegas, NV by specialty
• Optometrist in Nevada

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.