Basic Information
| Provider Information | |||||||||
| NPI: | 1962692160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIGNATURE EYE CARE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5630 S 84TH ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685164470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024882211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5630 S 84TH ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685164470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024882211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | KNUTSON | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | GLYNDON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4024882211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1147 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 10025538200 | 05 | NE | MEDICAID |