Provider Demographics
NPI:1902383631
Name:ARKANSAS FAMILY EYECARE OF MALVERN
Entity Type:Organization
Organization Name:ARKANSAS FAMILY EYECARE OF MALVERN
Other - Org Name:JUSTUS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TASKER
Authorized Official - Middle Name:
Authorized Official - Last Name:RODMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
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:501-225-9944
Mailing Address - Fax:501-225-9933
Practice Address - Street 1:1023 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-5222
Practice Address - Country:US
Practice Address - Phone:501-332-6262
Practice Address - Fax:501-337-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
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
AR232911722Medicaid