Provider Demographics
NPI:1922796911
Name:BRYANT VISION CLINIC LLC
Entity Type:Organization
Organization Name:BRYANT VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:NOELL
Authorized Official - Last Name:HAVILAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:731-415-7918
Mailing Address - Street 1:3003 LACROSS DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-9327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2213 N REYNOLDS RD STE 1
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-2501
Practice Address - Country:US
Practice Address - Phone:731-415-7918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty