Provider Demographics
NPI:1902478449
Name:SHEPHERD EYE CENTER, LTD
Entity Type:Organization
Organization Name:SHEPHERD EYE CENTER, LTD
Other - Org Name:NEW EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-202-4776
Mailing Address - Street 1:2020 WELLNESS WAY STE 402
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4145
Mailing Address - Country:US
Mailing Address - Phone:702-485-5000
Mailing Address - Fax:702-485-5001
Practice Address - Street 1:2020 WELLNESS WAY STE 402
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4145
Practice Address - Country:US
Practice Address - Phone:702-485-5000
Practice Address - Fax:702-485-5005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHEPHERD EYE CENTER, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-14
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1902478449Medicaid