Provider Demographics
NPI:1992014526
Name:ALAN L LATOURETTE ESTATE VICKI C LATOURETTE EX
Entity Type:Organization
Organization Name:ALAN L LATOURETTE ESTATE VICKI C LATOURETTE EX
Other - Org Name:TRI STATE OPTICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTRIX OF ALAN LATOURETTE ESTATE
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:C
Authorized Official - Last Name:LATOURETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-2012
Mailing Address - Street 1:1401 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3317
Mailing Address - Country:US
Mailing Address - Phone:479-636-2012
Mailing Address - Fax:479-631-7416
Practice Address - Street 1:1401 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3317
Practice Address - Country:US
Practice Address - Phone:479-636-2012
Practice Address - Fax:479-631-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185799722Medicaid
AR5G698Medicare PIN