Provider Demographics
NPI:1477037000
Name:EYE STATE OPTOMETRY, LLC
Entity Type:Organization
Organization Name:EYE STATE OPTOMETRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALLORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-293-0708
Mailing Address - Street 1:101 CYCLONE LN
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-7610
Mailing Address - Country:US
Mailing Address - Phone:515-293-0708
Mailing Address - Fax:
Practice Address - Street 1:3105 GRAND AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-4604
Practice Address - Country:US
Practice Address - Phone:515-441-8127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center