Provider Demographics
NPI:1649397126
Name:PROGRESSIVE EYE CENTER INC
Entity Type:Organization
Organization Name:PROGRESSIVE EYE CENTER INC
Other - Org Name:OZARK EYE CENTER OF HIGHLAND
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-257-2100
Mailing Address - Street 1:197 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-0000
Mailing Address - Country:US
Mailing Address - Phone:870-257-2100
Mailing Address - Fax:870-257-4395
Practice Address - Street 1:197 HOSPITAL DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529-0000
Practice Address - Country:US
Practice Address - Phone:870-257-2100
Practice Address - Fax:870-257-4395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2408152W00000X
ARAR2408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128855722Medicaid
AR123535722Medicaid
AR5B794Medicare ID - Type Unspecified
AR123535722Medicaid