Provider Demographics
NPI:1750362174
Name:BOONE VISION CENTER LLC
Entity type:Organization
Organization Name:BOONE VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-432-2973
Mailing Address - Street 1:621 STORY ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-2833
Mailing Address - Country:US
Mailing Address - Phone:515-432-2973
Mailing Address - Fax:515-432-1811
Practice Address - Street 1:621 STORY ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-2833
Practice Address - Country:US
Practice Address - Phone:515-432-2973
Practice Address - Fax:515-432-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA1854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0480863Medicaid
CJ8678OtherRRM RAILROAD MEDICARE
IA4512050001Medicare NSC
CJ8678OtherRRM RAILROAD MEDICARE
IA0480863Medicaid