Basic Information
| Provider Information | |||||||||
| NPI: | 1740461979 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNATIONAL EYECARE CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MALBAR VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 N 78TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023934500 | ||||||||
| FaxNumber: | 4023937457 | ||||||||
| Practice Location | |||||||||
| Address1: | 8102 S 84TH ST | ||||||||
| Address2: | |||||||||
| City: | LAVISTA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681283305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023395550 | ||||||||
| FaxNumber: | 4023395554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHORT | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6184629818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 470486594 | NE | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 47048659409 | 05 | NE | MEDICAID |