Provider Demographics
NPI:1053643817
Name:DRAKE, MICKEY LEE I (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:LEE
Last Name:DRAKE
Suffix:I
Gender:M
Credentials:OPTICIAN
Other - Prefix:MRS
Other - First Name:JILL
Other - Middle Name:ANN
Other - Last Name:DRAKE
Other - Suffix:II
Other - Last Name Type:Former Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:111 PONDEROSA LN
Mailing Address - Street 2:SUITE H
Mailing Address - City:HOT SPRINGS VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71909-5018
Mailing Address - Country:US
Mailing Address - Phone:501-984-5955
Mailing Address - Fax:501-984-5955
Practice Address - Street 1:111 PONDEROSA LN
Practice Address - Street 2:SUITE H
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909-5018
Practice Address - Country:US
Practice Address - Phone:501-984-5955
Practice Address - Fax:501-984-5955
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL-981101156FX1800X
ARL-030454156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician