Healthcare Provider Details

I. General information

NPI: 1083548853
Provider Name (Legal Business Name): NORTHEAST IOWA OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E SAN MARNAN DR
WATERLOO IA
50702-5611
US

IV. Provider business mailing address

909 E SAN MARNAN DR
WATERLOO IA
50702-5611
US

V. Phone/Fax

Practice location:
  • Phone: 830-320-3852
  • Fax: 830-341-5593
Mailing address:
  • Phone: 830-320-3852
  • Fax: 830-341-5593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL MILLER
Title or Position: OWNER/PROVIDER
Credential:
Phone: 830-320-3852