Provider Demographics
NPI:1780762229
Name:EYECARE CENTRE
Entity type:Organization
Organization Name:EYECARE CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-262-1589
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-0707
Mailing Address - Country:US
Mailing Address - Phone:712-262-1589
Mailing Address - Fax:712-262-3689
Practice Address - Street 1:3 E 18TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-3441
Practice Address - Country:US
Practice Address - Phone:712-262-1589
Practice Address - Fax:712-262-3689
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYECARE CENTRE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02135152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0198416Medicaid
IA05577OtherBLUE CROSS BLUE SHIELD
IA05577OtherBLUE CROSS BLUE SHIELD
IAU77794Medicare UPIN
IA71993Medicare ID - Type Unspecified