MEDICARE: INTERNATIONAL EYECARE CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1235455320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNATIONAL EYECARE CENTER, INC

Provider Business Mailing Address
First Line	:	1877 N BLUFF ST
Second Line	:	A
City	:	FULTON
State	:	MO
Zip	:	65251-2465
Country	:	US
Telephone Number	:	573-592-7484
Fax Number	:

Provider Business Practice Location Address
First Line	:	1877A N BLUFF ST
Second Line	:
City	:	FULTON
State	:	MO
Zip	:	65251-2465
Country	:	US
Telephone Number	:	573-592-7484
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIAILING MANAGER
Name	:	CATHY LEE SHORT
Credential	:
Telephone Number	:	618-462-9818

Provider Enumeration Date	:	04/14/2010
Last Update Date	:	01/22/2021

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