1598055188 NPI number — KNOX EYECARE

Table of content: (NPI 1598055188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598055188 NPI number — KNOX EYECARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KNOX EYECARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598055188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 ALABAR AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-233-5096
Provider Business Mailing Address Fax Number:
319-287-9022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 ALABAR AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-233-5096
Provider Business Practice Location Address Fax Number:
319-287-9022
Provider Enumeration Date:
04/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KNOX
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OPTOMETRIST/OWNER
Authorized Official Telephone Number:
319-233-5096

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02141 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 952658 . This is a "EYEMED" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598055188 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: IB2167001 . This is a "MEDICARE PTAN INDIVIDUAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 62742 . This is a "AVESIS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: IB2167 . This is a "MEDICARE PTAN ORGANIZATION" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598055188 . This is a "WELLMARK BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 69203 . This is a "DAVIS VISION" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598055188 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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