Provider Demographics
NPI:1053486803
Name:DEBLACK EYE CARE CENTER, P.A.
Entity Type:Organization
Organization Name:DEBLACK EYE CARE CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:SANDERS
Authorized Official - Last Name:DEBLACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-329-7878
Mailing Address - Street 1:4150 TYLER STREET,
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-329-7878
Mailing Address - Fax:501-329-7881
Practice Address - Street 1:4150 TYLER STREET,
Practice Address - Street 2:SUITE 1
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-329-7878
Practice Address - Fax:501-329-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F624Medicare ID - Type Unspecified