=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740461979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL EYECARE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 01/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8102 S 84TH ST
-----------------------------------------------------
City | LAVISTA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68128-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-339-5550
-----------------------------------------------------
Fax | 402-339-5554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 N 78TH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68114-3638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-393-4500
-----------------------------------------------------
Fax | 402-393-7457
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | CATHY LEE SHORT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-462-9818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 470486594
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------