Provider Demographics
NPI:1407119985
Name:EAGLE MOUNTAIN EYE CARE
Entity Type:Organization
Organization Name:EAGLE MOUNTAIN EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-382-2974
Mailing Address - Street 1:3150 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7515
Mailing Address - Country:US
Mailing Address - Phone:870-793-6544
Mailing Address - Fax:870-793-7024
Practice Address - Street 1:3150 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7515
Practice Address - Country:US
Practice Address - Phone:870-793-6544
Practice Address - Fax:870-793-7024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
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
AR5G795Medicare PIN