Provider Demographics
NPI:1215008164
Name:L.D PECK,PC
Entity Type:Organization
Organization Name:L.D PECK,PC
Other - Org Name:VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:319-524-3651
Mailing Address - Street 1:1813 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3326
Mailing Address - Country:US
Mailing Address - Phone:319-524-3651
Mailing Address - Fax:319-524-6118
Practice Address - Street 1:1813 MAIN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3326
Practice Address - Country:US
Practice Address - Phone:319-524-3651
Practice Address - Fax:319-524-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1900894Medicaid
IA1900894Medicaid
IA0263890001Medicare NSC