Provider Demographics
NPI:1558427021
Name:PEDIATRIC VISION DEVELOPMENT CENTER INC.
Entity Type:Organization
Organization Name:PEDIATRIC VISION DEVELOPMENT CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-795-1411
Mailing Address - Street 1:101 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9314
Mailing Address - Country:US
Mailing Address - Phone:479-795-1411
Mailing Address - Fax:479-795-1412
Practice Address - Street 1:101 DAWN DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9314
Practice Address - Country:US
Practice Address - Phone:479-795-1411
Practice Address - Fax:479-795-1412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2568152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2568OtherSTATE LICENSE
AR2568OtherSTATE LICENSE