Provider Demographics
NPI:1063059186
Name:EMMETSBURG EYE CLINIC
Entity type:Organization
Organization Name:EMMETSBURG EYE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:REEDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:712-852-2979
Mailing Address - Street 1:2217 MAIN ST # 329
Mailing Address - Street 2:
Mailing Address - City:EMMETSBURG
Mailing Address - State:IA
Mailing Address - Zip Code:50536-2446
Mailing Address - Country:US
Mailing Address - Phone:319-230-9110
Mailing Address - Fax:712-852-2024
Practice Address - Street 1:2217 MAIN ST # 329
Practice Address - Street 2:
Practice Address - City:EMMETSBURG
Practice Address - State:IA
Practice Address - Zip Code:50536-2446
Practice Address - Country:US
Practice Address - Phone:319-230-9110
Practice Address - Fax:712-852-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01629OtherLICENSE NUMBER