Provider Demographics
NPI:1750451449
Name:PROFESSIONAL EYE CARE ASSOCIATES PA
Entity Type:Organization
Organization Name:PROFESSIONAL EYE CARE ASSOCIATES PA
Other - Org Name:FANT EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:ORGAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-831-5706
Mailing Address - Street 1:PO BOX 9628
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0028
Mailing Address - Country:US
Mailing Address - Phone:903-831-5706
Mailing Address - Fax:903-832-4450
Practice Address - Street 1:2901 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2125
Practice Address - Country:US
Practice Address - Phone:903-831-5706
Practice Address - Fax:903-832-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1201880001Medicare NSC
TX00E88WMedicare PIN