1053643817 NPI number — MR. MICKEY LEE DRAKE I OPTICIAN

Table of content: MR. MICKEY LEE DRAKE I OPTICIAN (NPI 1053643817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053643817 NPI number — MR. MICKEY LEE DRAKE I OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAKE
Provider First Name:
MICKEY
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
OPTICIAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DRAKE
Provider Other First Name:
JILL
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
II
Provider Other Credential Text:
OPTICIAN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053643817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 PONDEROSA LN
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
HOT SPRINGS VILLAGE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71909-5018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-984-5955
Provider Business Mailing Address Fax Number:
501-984-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 PONDEROSA LN
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
HOT SPRINGS VILLAGE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71909-5018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-984-5955
Provider Business Practice Location Address Fax Number:
501-984-5955
Provider Enumeration Date:
02/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  L-981101 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156FX1800X , with the licence number: L-030454 , 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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