Provider Demographics
NPI:1316382302
Name:GREAT RIVER EYE CARE, INC.
Entity Type:Organization
Organization Name:GREAT RIVER EYE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-754-5022
Mailing Address - Street 1:3337 AGENCY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-1959
Mailing Address - Country:US
Mailing Address - Phone:319-754-5022
Mailing Address - Fax:319-754-0411
Practice Address - Street 1:3337 AGENCY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-1959
Practice Address - Country:US
Practice Address - Phone:319-754-5022
Practice Address - Fax:319-754-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-03
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1761152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0008839Medicaid
IA0326920001Medicare UPIN
IA0008839Medicaid