Healthcare Provider Details

I. General information

NPI: 1750570446
Provider Name (Legal Business Name): RIVERSIDE FAMILY EYE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S CODY RD
LE CLAIRE IA
52753-9236
US

IV. Provider business mailing address

PO BOX 6
LE CLAIRE IA
52753-0006
US

V. Phone/Fax

Practice location:
  • Phone: 563-289-2020
  • Fax: 563-289-2011
Mailing address:
  • Phone: 563-289-2020
  • Fax: 563-289-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number2189
License Number StateIA

VIII. Authorized Official

Name: LISA ANNE NIX
Title or Position: OPTOMETRIST
Credential: OD
Phone: 563-289-2020