Basic Information
Provider Information | |||||||||
NPI: | 1831368133 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERNATIONAL EYECARE CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MALBAR VISION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 409 N 78TH ST | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681143638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023934500 | ||||||||
FaxNumber: | 4023937457 | ||||||||
Practice Location | |||||||||
Address1: | 16016 EVANS STREET | ||||||||
Address2: | SUITE 101 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 68116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024933224 | ||||||||
FaxNumber: | 4024934041 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2008 | ||||||||
LastUpdateDate: | 01/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHORT | ||||||||
AuthorizedOfficialFirstName: | CATHY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6184629818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   | 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 | 47048659410 | 05 | NE |   | MEDICAID |