1689932915 NPI number — PROGRESSIVE EYE CENTER & BOUTIQUE

Table of content: MR. ROBERT JAMES LANE JR. LANE'S D.S. TRANSPOR (NPI 1104239383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689932915 NPI number — PROGRESSIVE EYE CENTER & BOUTIQUE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE EYE CENTER & BOUTIQUE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689932915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASH FLAT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72513-0158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-257-2100
Provider Business Mailing Address Fax Number:
870-257-4395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 CRESTWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72116-7623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-758-9500
Provider Business Practice Location Address Fax Number:
501-753-4311
Provider Enumeration Date:
04/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
HERMAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-257-2100

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2408 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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