=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932200052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE ASSOCIATES SIOUXLAND, P.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 PIERCE ST STE 404
-----------------------------------------------------
City | SIOUX CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51104-3759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-233-1529
-----------------------------------------------------
Fax | 712-233-2040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 PIERCE ST STE 404
-----------------------------------------------------
City | SIOUX CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51104-3759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-233-1529
-----------------------------------------------------
Fax | 712-233-2040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE MANAGER
-----------------------------------------------------
Name | MRS. BECKY MARSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 712-233-1529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 28135
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------