Provider Demographics
NPI:1043558299
Name:INTERNATIONAL EYECARE CENTER INC
Entity Type:Organization
Organization Name:INTERNATIONAL EYECARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MVC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-741-8183
Mailing Address - Street 1:125 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1705
Mailing Address - Country:US
Mailing Address - Phone:641-437-4099
Mailing Address - Fax:641-437-4099
Practice Address - Street 1:125 N 13TH ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1705
Practice Address - Country:US
Practice Address - Phone:641-437-4099
Practice Address - Fax:641-437-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-23
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1760405047Medicaid