Provider Demographics
NPI:1265661938
Name:COCKRUM VISION CLINIC
Entity Type:Organization
Organization Name:COCKRUM VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-425-1112
Mailing Address - Street 1:2183 HIGHWAY 62 W
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-6500
Mailing Address - Country:US
Mailing Address - Phone:870-425-1112
Mailing Address - Fax:870-425-1278
Practice Address - Street 1:2183 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-6500
Practice Address - Country:US
Practice Address - Phone:870-425-1112
Practice Address - Fax:870-425-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2230152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110615722Medicaid