MEDICARE: INDEPENDENT OPTICAL DISPENSARY,INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier		IA

General Provider Information

NPI Number	:	1043482656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT OPTICAL DISPENSARY,INC.

Provider Business Mailing Address
First Line	:	106 S 4TH ST
Second Line	:
City	:	CLINTON
State	:	IA
Zip	:	52732-4425
Country	:	US
Telephone Number	:	563-243-1650
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 S 4TH ST
Second Line	:
City	:	CLINTON
State	:	IA
Zip	:	52732-4425
Country	:	US
Telephone Number	:	563-243-1650
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED OPTICIAN
Name	:	MR. STANLEY E. DIERKS
Credential	:
Telephone Number	:	563-243-1650

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	10/17/2008

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