Provider Demographics
NPI:1942326244
Name:ARKANSAS VISION DEVELOPMENT CENTER PA
Entity Type:Organization
Organization Name:ARKANSAS VISION DEVELOPMENT CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-478-8860
Mailing Address - Street 1:1021 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2549
Mailing Address - Country:US
Mailing Address - Phone:479-478-8860
Mailing Address - Fax:479-478-8890
Practice Address - Street 1:1021 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2549
Practice Address - Country:US
Practice Address - Phone:479-478-8860
Practice Address - Fax:479-478-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2554152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49907OtherMEDICARE PTAN
AR158686722Medicaid
AR1942326244OtherNPI GROUP
OK200057240AMedicaid
AR1447387170OtherNPI INDIVIDUAL
OK200055390AMedicaid
AR5F232OtherGROUP PTAN
AR158686722Medicaid