Provider Demographics
NPI:1518054055
Name:SOUTHERN EYE ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHERN EYE ASSOCIATES
Other - Org Name:ERWIN EYE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-935-6396
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:AR
Mailing Address - Zip Code:72422-0037
Mailing Address - Country:US
Mailing Address - Phone:870-857-6556
Mailing Address - Fax:870-857-3787
Practice Address - Street 1:609 N MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-1617
Practice Address - Country:US
Practice Address - Phone:870-857-6556
Practice Address - Fax:870-857-3787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2293152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0348860004Medicare NSC