Provider Demographics
NPI:1033421219
Name:JENSEN EYECARE CENTER PLLC
Entity Type:Organization
Organization Name:JENSEN EYECARE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MON
Authorized Official - Middle Name:
Authorized Official - Last Name:KEOMANIVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-338-6700
Mailing Address - Street 1:640 HIGHWAY 1 W
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-4218
Mailing Address - Country:US
Mailing Address - Phone:319-338-6700
Mailing Address - Fax:319-887-1101
Practice Address - Street 1:640 HIGHWAY 1 W
Practice Address - Street 2:SUITE 2
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-4218
Practice Address - Country:US
Practice Address - Phone:319-338-6700
Practice Address - Fax:319-887-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-05
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB1893Medicare PIN