1932103611 NPI number — DRIESEN EYE CENTER, P.C.

Table of content: (NPI 1932103611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932103611 NPI number — DRIESEN EYE CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRIESEN EYE CENTER, P.C.
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:
1932103611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CENTER
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51250-0020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-722-2051
Provider Business Mailing Address Fax Number:
712-722-4531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX CENTER
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51250-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-722-2051
Provider Business Practice Location Address Fax Number:
712-722-4531
Provider Enumeration Date:
06/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEYERS
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
712-722-2051

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1974 , 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: 44793 . This is a "BC/BS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0121871 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG1306 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".