Provider Demographics
NPI:1336337518
Name:CRESCO FAMILY OPTOMETRY LLC
Entity type:Organization
Organization Name:CRESCO FAMILY OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LEEPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-547-5363
Mailing Address - Street 1:213 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-1521
Mailing Address - Country:US
Mailing Address - Phone:563-547-5363
Mailing Address - Fax:563-547-2621
Practice Address - Street 1:213 N ELM ST
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1521
Practice Address - Country:US
Practice Address - Phone:563-547-5363
Practice Address - Fax:563-547-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0476465Medicaid
IA0476465Medicaid
IAT01338Medicare UPIN
IA5185110001Medicare NSC