Provider Demographics
NPI:1114224201
Name:VANCE VISION CLINIC PA
Entity Type:Organization
Organization Name:VANCE VISION CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-382-2974
Mailing Address - Street 1:1200 W MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COTTER
Mailing Address - State:AR
Mailing Address - Zip Code:72626-9777
Mailing Address - Country:US
Mailing Address - Phone:870-435-3333
Mailing Address - Fax:870-435-1333
Practice Address - Street 1:1200 W MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:COTTER
Practice Address - State:AR
Practice Address - Zip Code:72626-9777
Practice Address - Country:US
Practice Address - Phone:870-435-3333
Practice Address - Fax:870-435-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187164722Medicaid
AR187164722Medicaid