Provider Demographics
NPI:1710167143
Name:LIEBLONG EYE CLINIC, PA
Entity Type:Organization
Organization Name:LIEBLONG EYE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHLOE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBLONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-968-2020
Mailing Address - Street 1:2800 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2449
Mailing Address - Country:US
Mailing Address - Phone:479-968-2020
Mailing Address - Fax:479-968-8803
Practice Address - Street 1:2800 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2449
Practice Address - Country:US
Practice Address - Phone:479-968-2020
Practice Address - Fax:479-968-8803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2265332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR410014279OtherRAILROAD RETIREMENT
AR103901722Medicaid
AR16617000041OtherQUAL CHOICE
AR0269470001Medicare NSC
AR16617000041OtherQUAL CHOICE
AR410014279OtherRAILROAD RETIREMENT