1003145319 NPI number — FAMILY EYE CARE CENTER, INC.

Table of content: (NPI 1003145319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003145319 NPI number — FAMILY EYE CARE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY EYE CARE CENTER, INC.
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:
1003145319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 CASH RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71701-3706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-836-2525
Provider Business Mailing Address Fax Number:
870-836-7252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 CASH RD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71701-3706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-836-2525
Provider Business Practice Location Address Fax Number:
870-836-7252
Provider Enumeration Date:
12/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
NUTT
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-836-2525

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2582 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2570 , 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)

  • Identifier: 57839 . This is a "ARK BCBS-MEDIPAK" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 181078722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57839 . This is a "BLUE ADVANTAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57839 . This is a "ARKANSAS BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 57839 . This is a "HEALTH ADVANTAGE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 57839 . This is a "MEDIPAK ADVANTAGE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 57839 . This is a "BLUE CARD/ AR BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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