Provider Demographics
NPI:1801887484
Name:EYECARE ASSOCIATES OF SOUTHWEST IOWA INC
Entity type:Organization
Organization Name:EYECARE ASSOCIATES OF SOUTHWEST IOWA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-542-6513
Mailing Address - Street 1:116 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-1611
Mailing Address - Country:US
Mailing Address - Phone:712-542-6513
Mailing Address - Fax:712-542-2274
Practice Address - Street 1:116 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-1611
Practice Address - Country:US
Practice Address - Phone:712-542-6513
Practice Address - Fax:712-542-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0201285Medicaid
IA07311OtherBCBS
NE100249544-00Medicaid
109192OtherEYEMED
IA1309730002Medicare NSC
IA07311OtherBCBS
CJ7740Medicare PIN