Provider Demographics
NPI:1750315040
Name:EYECARE CENTRE
Entity Type:Organization
Organization Name:EYECARE CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:CORNWALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-336-1960
Mailing Address - Street 1:2312 23RD STREET
Mailing Address - Street 2:PO BOX AG
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-0328
Mailing Address - Country:US
Mailing Address - Phone:712-336-1960
Mailing Address - Fax:
Practice Address - Street 1:2312 23RD STREET
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-0328
Practice Address - Country:US
Practice Address - Phone:712-336-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02082152W00000X
IA01903152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0286104Medicaid
IA29415OtherGROUP WELLMARK BCBS
IA1162032Medicaid
IA28610OtherDR. N WELLMARK BCBS
IA40832OtherDR. C. WELLMARK BCBS
IA0343680002Medicare NSC
IA28610OtherDR. N WELLMARK BCBS
IA0286104Medicaid
IA1162032Medicaid