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General NPI Number Information
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NPI Number | 1467501981
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Entity Type | Organization
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Legal Business Name | TKC OPTICAL
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 08/09/2021
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Provider Practice Location Address
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Address Line | 100 E MILWAUKEE AVE
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City | STORM LAKE
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State | IA
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Zip | 50588-1813
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Country | US
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Telephone | 712-732-7624
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 4TH ST
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City | SIOUX CITY
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State | IA
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Zip | 51101-2118
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Country | US
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Telephone | 712-732-7624
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Fax | 712-732-7627
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | CLARENCE JOSEPH VANDERLEI
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Credential | OD
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Telephone | 712-732-7624
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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