Provider Demographics
NPI:1588866941
Name:VISION CLINIC, PC
Entity type:Organization
Organization Name:VISION CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WYLIE
Authorized Official - Last Name:HARTZELL
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:515-274-4141
Mailing Address - Street 1:2628 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3908
Mailing Address - Country:US
Mailing Address - Phone:515-274-4141
Mailing Address - Fax:515-274-4144
Practice Address - Street 1:2628 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3908
Practice Address - Country:US
Practice Address - Phone:515-274-4141
Practice Address - Fax:515-274-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1174700001Medicare NSC