Provider Demographics
NPI:1356876577
Name:LITTLE ROCK AIR FORCE BASE EYE CARE
Entity type:Organization
Organization Name:LITTLE ROCK AIR FORCE BASE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:PROF
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-983-0106
Mailing Address - Street 1:6TH STREET, BLDG 787
Mailing Address - Street 2:LITTLE ROCK AIR FORCE BASE
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72099
Mailing Address - Country:US
Mailing Address - Phone:501-983-0106
Mailing Address - Fax:501-983-0008
Practice Address - Street 1:6TH STREET, BLDG 787
Practice Address - Street 2:LITTLE ROCK AIR FORCE BASE
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72099
Practice Address - Country:US
Practice Address - Phone:501-983-0106
Practice Address - Fax:501-983-0008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAUMELLE EYE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty