Provider Demographics
NPI:1730669433
Name:EYEWEAR GALLERY
Entity Type:Organization
Organization Name:EYEWEAR GALLERY
Other - Org Name:MAQUOKETA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAYWARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-659-2020
Mailing Address - Street 1:101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060
Mailing Address - Country:US
Mailing Address - Phone:563-652-2020
Mailing Address - Fax:563-652-9097
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060
Practice Address - Country:US
Practice Address - Phone:563-659-2020
Practice Address - Fax:563-659-2121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEWEAR GALLERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-21
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty