Provider Demographics
NPI:1043292949
Name:FAMILY EYE CARE OF IDA GROVE PC
Entity Type:Organization
Organization Name:FAMILY EYE CARE OF IDA GROVE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-364-3118
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-0238
Mailing Address - Country:US
Mailing Address - Phone:712-364-3118
Mailing Address - Fax:712-364-4144
Practice Address - Street 1:415 2ND ST
Practice Address - Street 2:
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1302
Practice Address - Country:US
Practice Address - Phone:712-364-3118
Practice Address - Fax:712-364-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1792283Medicaid
IA=========OtherSECURE HORIZONS
IA=========OtherUNICARE
IA=========OtherPYRAMID
IA=========OtherVSP
IA=========OtherPRINCIPAL
IA=========OtherADVANTRA
IA=========OtherHUMANA
IA=========OtherMEDICARE COMPLETE
IA=========OtherMIDLANDS CHOICE
IA=========OtherADVANTRA FREEDOM
IA1792283Medicaid
IA=========OtherADVANTRA FREEDOM
IA1792283Medicaid
IACS8765Medicare PIN