1043558299 NPI number — INTERNATIONAL EYECARE CENTER INC

Table of content: (NPI 1043558299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043558299 NPI number — INTERNATIONAL EYECARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNATIONAL EYECARE CENTER INC
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:
1043558299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 N 13TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52544-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-437-4099
Provider Business Mailing Address Fax Number:
641-437-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 N 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52544-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-437-4099
Provider Business Practice Location Address Fax Number:
641-437-4099
Provider Enumeration Date:
01/23/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALLISON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
MVC DIRECTOR
Authorized Official Telephone Number:
314-741-8183

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1760405047 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".