Provider Demographics
NPI:1427194919
Name:BERRYVILLE EYECARE CLINIC
Entity Type:Organization
Organization Name:BERRYVILLE EYECARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCTS RECD
Authorized Official - Prefix:
Authorized Official - First Name:MARANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-350-0777
Mailing Address - Street 1:11225 HURON LN STE 200A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1861
Mailing Address - Country:US
Mailing Address - Phone:870-423-2576
Mailing Address - Fax:870-423-6750
Practice Address - Street 1:404 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3142
Practice Address - Country:US
Practice Address - Phone:870-423-2576
Practice Address - Fax:870-423-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166252722Medicaid
ARDH1487OtherRAILROAD MEDICARE
AR5F769Medicare UPIN