Basic Information
| Provider Information | |||||||||
| NPI: | 1548215395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISION CARE CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 E ERIE ST | ||||||||
| Address2: | |||||||||
| City: | MISSOURI VALLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515551619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126424146 | ||||||||
| FaxNumber: | 7126423091 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 E ERIE ST | ||||||||
| Address2: | |||||||||
| City: | MISSOURI VALLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515551619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126424146 | ||||||||
| FaxNumber: | 7126423091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | BOWKER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7122632020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | A004235 | 01 | IA | CHAMPUS | OTHER | 0485581 | 05 | IA | MEDICAID | 39891 | 01 | IA | WELLMARK | OTHER | 42149719 | 01 | IA | COMMERCIAL & OTHER STATES | OTHER |