Provider Demographics
NPI:1376542787
Name:INTERNATIONAL EYECARE CENTER, INC.
Entity Type:Organization
Organization Name:INTERNATIONAL EYECARE CENTER, INC.
Other - Org Name:MALBAR VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:409 N 78TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3638
Mailing Address - Country:US
Mailing Address - Phone:402-393-4500
Mailing Address - Fax:402-393-7457
Practice Address - Street 1:409 N 78TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3638
Practice Address - Country:US
Practice Address - Phone:402-391-6600
Practice Address - Fax:402-393-6890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2021-01-22
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
NE47048659404Medicaid
NE=========04Medicaid
NECH5064Medicare PIN
NE098041Medicare PIN