Provider Demographics
NPI:1154638153
Name:TRI-STATE OPTICAL CENTER, PLLC
Entity Type:Organization
Organization Name:TRI-STATE OPTICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-636-2012
Mailing Address - Street 1:1401 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3317
Mailing Address - Country:US
Mailing Address - Phone:479-636-2012
Mailing Address - Fax:
Practice Address - Street 1:1401 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3317
Practice Address - Country:US
Practice Address - Phone:479-636-2012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-12
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185238722Medicaid
AR5G666Medicare PIN
AR6628850001Medicare NSC
DS2977Medicare PIN