Provider Demographics
NPI:1669651311
Name:BENTON EYECARE CLINIC
Entity Type:Organization
Organization Name:BENTON EYECARE CLINIC
Other - Org Name:TASKER RODMAN GEN PTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TASKER
Authorized Official - Middle Name:
Authorized Official - Last Name:RODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-225-9944
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:501-778-2020
Mailing Address - Fax:501-778-1788
Practice Address - Street 1:443 HIGHWAY 5 N
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-9778
Practice Address - Country:US
Practice Address - Phone:501-778-2020
Practice Address - Fax:501-778-1788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175933722Medicaid