Healthcare Provider Details

I. General information

NPI: 1598055188
Provider Name (Legal Business Name): KNOX EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 ALABAR AVE.
WATERLOO IA
50701
US

IV. Provider business mailing address

1030 ALABAR AVE.
WATERLOO IA
50701
US

V. Phone/Fax

Practice location:
  • Phone: 319-233-5096
  • Fax: 319-287-9022
Mailing address:
  • Phone: 319-233-5096
  • Fax: 319-287-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02141
License Number StateIA

VIII. Authorized Official

Name: DR. BRADLEY JOSEPH KNOX
Title or Position: OPTOMETRIST/OWNER
Credential: O.D.
Phone: 319-233-5096