Provider Demographics
NPI:1104974476
Name:FAMILY EYECARE OF WINTERSET PC
Entity type:Organization
Organization Name:FAMILY EYECARE OF WINTERSET PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JOHLL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-462-1254
Mailing Address - Street 1:102 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273-1551
Mailing Address - Country:US
Mailing Address - Phone:515-462-1254
Mailing Address - Fax:
Practice Address - Street 1:102 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-1551
Practice Address - Country:US
Practice Address - Phone:515-462-1254
Practice Address - Fax:515-462-2895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01925152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0400155Medicaid
5813460001Medicare NSC
I19649Medicare PIN
IA0400155Medicaid