Provider Demographics
NPI:1124020177
Name:PENELOPE A HAEKER OD PLC
Entity Type:Organization
Organization Name:PENELOPE A HAEKER OD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAEKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-224-4600
Mailing Address - Street 1:5001 SERGEANT RD
Mailing Address - Street 2:SUITE 45
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4775
Mailing Address - Country:US
Mailing Address - Phone:712-224-4600
Mailing Address - Fax:712-276-3716
Practice Address - Street 1:5001 SERGEANT RD
Practice Address - Street 2:SUITE 45
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4775
Practice Address - Country:US
Practice Address - Phone:712-224-4600
Practice Address - Fax:712-276-3716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI10446Medicare ID - Type Unspecified
U51094Medicare UPIN