Provider Demographics
NPI:1588029938
Name:EYEWEAR GALLERY
Entity Type:Organization
Organization Name:EYEWEAR GALLERY
Other - Org Name:DEWITT EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-659-2020
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-0050
Mailing Address - Country:US
Mailing Address - Phone:563-659-2020
Mailing Address - Fax:563-659-2121
Practice Address - Street 1:1107 9TH AVE
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1053
Practice Address - Country:US
Practice Address - Phone:563-659-2020
Practice Address - Fax:563-659-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty