Healthcare Provider Details

I. General information

NPI: 1750568796
Provider Name (Legal Business Name): INTERNATIONAL EYECARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W JACKSON ST
MEXICO MO
65265-1937
US

IV. Provider business mailing address

520 W JACKSON ST
MEXICO MO
65265-1937
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-7007
  • Fax:
Mailing address:
  • Phone: 573-581-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: CATHY LEE SHORT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 618-462-9818