Provider Demographics
NPI:1982792339
Name:CRESTON VISION CLINIC PC
Entity Type:Organization
Organization Name:CRESTON VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCKIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:641-782-7619
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-0427
Mailing Address - Country:US
Mailing Address - Phone:641-782-7619
Mailing Address - Fax:641-782-6549
Practice Address - Street 1:1610 W TOWNLINE ST STE 115
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1064
Practice Address - Country:US
Practice Address - Phone:641-782-7619
Practice Address - Fax:641-782-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF5361OtherRAILROAD MEDICARE
DF5361OtherRAILROAD MEDICARE
IAI7311Medicare PIN