Provider Demographics
NPI:1043482656
Name:INDEPENDENT OPTICAL DISPENSARY,INC.
Entity Type:Organization
Organization Name:INDEPENDENT OPTICAL DISPENSARY,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIERKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-243-1650
Mailing Address - Street 1:106 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-4425
Mailing Address - Country:US
Mailing Address - Phone:563-243-1650
Mailing Address - Fax:
Practice Address - Street 1:106 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-4425
Practice Address - Country:US
Practice Address - Phone:563-243-1650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0642300001Medicare NSC