Provider Demographics
NPI:1215025119
Name:SOUTHERN EYE ASSOCIATES, LTD
Entity Type:Organization
Organization Name:SOUTHERN EYE ASSOCIATES, LTD
Other - Org Name:MCHANEY VISION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:O.D.
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-886-2632
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0088
Mailing Address - Country:US
Mailing Address - Phone:870-886-2632
Mailing Address - Fax:870-886-1514
Practice Address - Street 1:1014 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1004
Practice Address - Country:US
Practice Address - Phone:870-886-2632
Practice Address - Fax:870-886-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102555722Medicaid
0348860002Medicare NSC
T20233Medicare UPIN
AR102555722Medicaid