1942326244 NPI number — ARKANSAS VISION DEVELOPMENT CENTER PA

Table of content: (NPI 1942326244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942326244 NPI number — ARKANSAS VISION DEVELOPMENT CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS VISION DEVELOPMENT CENTER PA
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:
1942326244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 S WALDRON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-2549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-478-8860
Provider Business Mailing Address Fax Number:
479-478-8890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 S WALDRON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-2549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-478-8860
Provider Business Practice Location Address Fax Number:
479-478-8890
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHN
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
479-478-8860

Provider Taxonomy Codes

  • Taxonomy code: 152WV0400X , with the licence number:  2554 , 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: 1447387170 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1942326244 . This is a "NPI GROUP" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5F232 . This is a "GROUP PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 158686722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200055390A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200057240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 49907 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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