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General NPI Number Information
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NPI Number | 1316382302
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Entity Type | Organization
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Legal Business Name | GREAT RIVER EYE CARE, INC.
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Dates
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Enumeration Date | 05/03/2013
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Last Update Date | 06/07/2013
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Provider Practice Location Address
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Address Line | 3337 AGENCY ST
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City | BURLINGTON
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State | IA
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Zip | 52601-1959
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Country | US
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Telephone | 319-754-5022
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Fax | 319-754-0411
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Provider Business Mailing Address
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Address Line | 3337 AGENCY ST
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City | BURLINGTON
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State | IA
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Zip | 52601-1959
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Country | US
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Telephone | 319-754-5022
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Fax | 319-754-0411
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | BRAD WEYERS
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Credential | O.D.
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Telephone | 319-754-5022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1761
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License Number State | IA
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