Provider Demographics
NPI:1568550754
Name:IOLA VISION SOURCE, LLC
Entity Type:Organization
Organization Name:IOLA VISION SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:620-365-2108
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-0847
Mailing Address - Country:US
Mailing Address - Phone:620-365-2108
Mailing Address - Fax:620-365-2522
Practice Address - Street 1:216 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-2943
Practice Address - Country:US
Practice Address - Phone:620-365-2108
Practice Address - Fax:620-365-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100642380AMedicaid
KSDA4480OtherRAILROAD MEDICARE #
KS5023680001Medicare NSC
KS100642380AMedicaid