Provider Demographics
NPI:1871542241
Name:WAKAN VISION INC
Entity type:Organization
Organization Name:WAKAN VISION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-898-3232
Mailing Address - Street 1:10826 OLD MILL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2660
Mailing Address - Country:US
Mailing Address - Phone:402-898-3232
Mailing Address - Fax:402-898-3234
Practice Address - Street 1:10826 OLD MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2660
Practice Address - Country:US
Practice Address - Phone:402-898-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1871542241Medicaid
NE10025795600Medicaid
CO33629013Medicaid
DC1477Medicare PIN
NENA1412Medicare PIN
CO467568Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NE10025795600Medicaid
CK7996Medicare PIN
UT000066783Medicare PIN
G02638Medicare PIN
CK4400Medicare PIN
DB5426Medicare PIN
NENA1410Medicare PIN
COC467568Medicare PIN
CO33629013Medicaid
UTDP3887Medicare PIN