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General NPI Number Information
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NPI Number | 1992462188
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Entity Type | Organization
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Legal Business Name | MADOPTICAL
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Dates
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Enumeration Date | 11/22/2021
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Last Update Date | 11/22/2021
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Provider Practice Location Address
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Address Line | 1441 MALL DR STE 400
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503-4728
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Country | US
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Telephone | 712-256-5515
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Fax | 712-256-8093
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Provider Business Mailing Address
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Address Line | 1441 MALL DR STE 400
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503-4728
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Country | US
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Telephone | 712-256-5515
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARK DICKEY
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Credential | ABO, NCLE
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Telephone | 402-639-3822
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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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