Provider Demographics
NPI:1417037219
Name:TYE, DELORES JEAN (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:DELORES
Middle Name:JEAN
Last Name:TYE
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60434 LEVI RD
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-5142
Mailing Address - Country:US
Mailing Address - Phone:712-527-9731
Mailing Address - Fax:
Practice Address - Street 1:2600 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3512
Practice Address - Country:US
Practice Address - Phone:712-322-3097
Practice Address - Fax:712-322-4130
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0797760001Medicare ID - Type Unspecified