Provider Demographics
NPI:1922319888
Name:ADVANCED EYE HEALTH
Entity Type:Organization
Organization Name:ADVANCED EYE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERUYTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-546-6868
Mailing Address - Street 1:1111 HOLTON DR
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2884
Mailing Address - Country:US
Mailing Address - Phone:712-546-6868
Mailing Address - Fax:712-546-6739
Practice Address - Street 1:1111 HOLTON DR
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2884
Practice Address - Country:US
Practice Address - Phone:712-546-6868
Practice Address - Fax:712-546-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA02253OtherLICENSE
IA02253OtherLICENSE