Healthcare Provider Details

I. General information

NPI: 1043558299
Provider Name (Legal Business Name): INTERNATIONAL EYECARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N 13TH ST
CENTERVILLE IA
52544-1705
US

IV. Provider business mailing address

125 N 13TH ST
CENTERVILLE IA
52544-1705
US

V. Phone/Fax

Practice location:
  • Phone: 641-437-4099
  • Fax: 641-437-4099
Mailing address:
  • Phone: 641-437-4099
  • Fax: 641-437-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ALLISON
Title or Position: MVC DIRECTOR
Credential:
Phone: 314-741-8183