Provider Demographics
NPI:1578635686
Name:MT VERNON EYE CLINIC PLC
Entity Type:Organization
Organization Name:MT VERNON EYE CLINIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEG
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-895-8888
Mailing Address - Street 1:202 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1588
Mailing Address - Country:US
Mailing Address - Phone:319-895-8888
Mailing Address - Fax:319-895-8889
Practice Address - Street 1:202 GLENN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1588
Practice Address - Country:US
Practice Address - Phone:319-895-8888
Practice Address - Fax:319-895-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0224055Medicaid
IA22405OtherBCBS
IA0224055Medicaid
IA1297250001Medicare NSC
IA410033159Medicare Oscar/Certification