Healthcare Provider Details

I. General information

NPI: 1912626821
Provider Name (Legal Business Name): EYEOWA WATERLOO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 AND 1525 E. SAN MARNAN DR
WATERLOO IA
50702
US

IV. Provider business mailing address

1523-1525 E. SAN MARNAN DRIVE
WATERLOO IA
50702
US

V. Phone/Fax

Practice location:
  • Phone: 956-335-6476
  • Fax: 561-828-8367
Mailing address:
  • Phone: 956-335-6476
  • Fax: 561-828-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DANIEL GARZA
Title or Position: MANAGED CARE MANAGER
Credential:
Phone: 561-275-2020