Provider Demographics
NPI:1558320325
Name:BOOZMAN-HOF REGIONAL EYE CLINIC PA
Entity Type:Organization
Organization Name:BOOZMAN-HOF REGIONAL EYE CLINIC PA
Other - Org Name:BOOZMAN-HOF OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHASTITY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-246-1700
Mailing Address - Street 1:3737 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-1839
Mailing Address - Country:US
Mailing Address - Phone:479-246-1700
Mailing Address - Fax:479-631-2629
Practice Address - Street 1:3737 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-1839
Practice Address - Country:US
Practice Address - Phone:479-246-1730
Practice Address - Fax:479-936-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101176716Medicaid
AR0346340001Medicare NSC