Provider Demographics
NPI:1053319061
Name:ADVANCED EYECARE ASSOCIATES OF CROSSETT, PA
Entity Type:Organization
Organization Name:ADVANCED EYECARE ASSOCIATES OF CROSSETT, PA
Other - Org Name:ADVANCED EYECARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-364-8996
Mailing Address - Street 1:1602 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-4154
Mailing Address - Country:US
Mailing Address - Phone:870-364-8996
Mailing Address - Fax:870-364-7363
Practice Address - Street 1:1602 MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-4154
Practice Address - Country:US
Practice Address - Phone:870-364-8996
Practice Address - Fax:870-364-7363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2416152W00000X
AR2246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR123601722Medicaid
AR102100722Medicaid
AR123619722Medicaid
AR410047149Medicare PIN
AR123619722Medicaid
AR410047177Medicare PIN
AR123601722Medicaid