Healthcare Provider Details

I. General information

NPI: 1063059186
Provider Name (Legal Business Name): EMMETSBURG EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 MAIN ST # 329
EMMETSBURG IA
50536-2446
US

IV. Provider business mailing address

2217 MAIN ST # 329
EMMETSBURG IA
50536-2446
US

V. Phone/Fax

Practice location:
  • Phone: 319-230-9110
  • Fax: 712-852-2024
Mailing address:
  • Phone: 319-230-9110
  • Fax: 712-852-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL JOSEPH REEDY JR.
Title or Position: MANAGER
Credential:
Phone: 712-852-2979