Provider Demographics
NPI:1841735008
Name:EYE CARE CENTER OF WAVERLY, PLLC
Entity Type:Organization
Organization Name:EYE CARE CENTER OF WAVERLY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:VAN DAALEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-559-2020
Mailing Address - Street 1:108 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2619
Mailing Address - Country:US
Mailing Address - Phone:319-559-2020
Mailing Address - Fax:319-559-2021
Practice Address - Street 1:108 2ND ST NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2619
Practice Address - Country:US
Practice Address - Phone:319-559-2020
Practice Address - Fax:319-559-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty