Healthcare Provider Details

I. General information

NPI: 1740461979
Provider Name (Legal Business Name): INTERNATIONAL EYECARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8102 S 84TH ST
LAVISTA NE
68128-3305
US

IV. Provider business mailing address

409 N 78TH ST
OMAHA NE
68114-3638
US

V. Phone/Fax

Practice location:
  • Phone: 402-339-5550
  • Fax: 402-339-5554
Mailing address:
  • Phone: 402-393-4500
  • Fax: 402-393-7457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number470486594
License Number StateNE

VIII. Authorized Official

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