Provider Demographics
NPI:1144530213
Name:GOTHENBURG-COZAD VISION CLINIC,P.C.
Entity type:Organization
Organization Name:GOTHENBURG-COZAD VISION CLINIC,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-537-2601
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-0449
Mailing Address - Country:US
Mailing Address - Phone:308-537-2601
Mailing Address - Fax:308-537-7211
Practice Address - Street 1:916 AVENUE F
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-2060
Practice Address - Country:US
Practice Address - Phone:308-537-2601
Practice Address - Fax:308-537-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE743332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE093216Medicare PIN
NE=========00Medicaid