Provider Demographics
NPI:1629194816
Name:TOTAL EYE HEALTH CENTER INC
Entity Type:Organization
Organization Name:TOTAL EYE HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-462-4891
Mailing Address - Street 1:603 E MAIN ST
Mailing Address - Street 2:PO BOX 398
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-1845
Mailing Address - Country:US
Mailing Address - Phone:319-462-4891
Mailing Address - Fax:319-462-4892
Practice Address - Street 1:603 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-1845
Practice Address - Country:US
Practice Address - Phone:319-462-4891
Practice Address - Fax:319-462-4892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0763078Medicaid
IADF8981OtherMEDICARE RAILROAD
IA28826OtherBLUE CROSS BLUE SHIELD
IADF8981OtherMEDICARE RAILROAD
IA0763078Medicaid