Provider Demographics
NPI:1689932915
Name:PROGRESSIVE EYE CENTER & BOUTIQUE
Entity Type:Organization
Organization Name:PROGRESSIVE EYE CENTER & BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:HERMAN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-257-2100
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-0158
Mailing Address - Country:US
Mailing Address - Phone:870-257-2100
Mailing Address - Fax:870-257-4395
Practice Address - Street 1:2520 CRESTWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7623
Practice Address - Country:US
Practice Address - Phone:501-758-9500
Practice Address - Fax:501-753-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6986750001Medicare NSC