1477615268 NPI number — TOBIN OPTICAL CENTER

Table of content: (NPI 1477615268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477615268 NPI number — TOBIN OPTICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOBIN OPTICAL CENTER
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:
1477615268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 VILLAGE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-279-1363
Provider Business Mailing Address Fax Number:
816-233-8936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 WOODBURY
Provider Second Line Business Practice Location Address:
SUITE 8B
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-328-2225
Provider Business Practice Location Address Fax Number:
712-325-4625
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOBIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
816-279-1363

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , 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: 4947192 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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