MEDICARE: EYE CARE ASSOCIATES OF CO LLC

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1104689165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE CARE ASSOCIATES OF CO LLC

Provider Business Mailing Address
First Line	:	PO BOX 879
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-0879
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1534 28TH AVE N
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-7602
Country	:	US
Telephone Number	:	515-573-1145
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MARQUETTA LATIMORE
Credential	:
Telephone Number	:	319-204-5326

Provider Enumeration Date	:	02/02/2024
Last Update Date	:	02/02/2024

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