Provider Demographics
NPI:1376620559
Name:PREWITT, VELVET (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:VELVET
Middle Name:
Last Name:PREWITT
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:VELVET'S
Other - Middle Name:
Other - Last Name:OPTIQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2511 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7424
Mailing Address - Country:US
Mailing Address - Phone:870-698-2020
Mailing Address - Fax:870-698-9371
Practice Address - Street 1:2511 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7424
Practice Address - Country:US
Practice Address - Phone:870-698-2020
Practice Address - Fax:870-698-9371
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL-930710156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4896680001Medicare NSC