Provider Demographics
NPI:1760627376
Name:GRAHAM CLOVERLEAF OPTICAL INC.
Entity Type:Organization
Organization Name:GRAHAM CLOVERLEAF OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-474-7878
Mailing Address - Street 1:2925 ALMA HWY STE C1
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5063
Mailing Address - Country:US
Mailing Address - Phone:479-474-7878
Mailing Address - Fax:479-471-1476
Practice Address - Street 1:113 N PLAZA CT
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2269
Practice Address - Country:US
Practice Address - Phone:479-474-7878
Practice Address - Fax:479-471-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2380152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR171400722Medicaid
AR0700220001Medicare NSC
AR48146Medicare PIN