Provider Demographics
NPI:1396053021
Name:PROGRESSIVE EYE CENTER OF PIGGOTT LLC
Entity type:Organization
Organization Name:PROGRESSIVE EYE CENTER OF PIGGOTT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:HERMAN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-598-2625
Mailing Address - Street 1:PO BOX 740
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-0740
Mailing Address - Country:US
Mailing Address - Phone:870-598-2625
Mailing Address - Fax:870-598-5676
Practice Address - Street 1:325 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PIGGOTT
Practice Address - State:AR
Practice Address - Zip Code:72454-2014
Practice Address - Country:US
Practice Address - Phone:870-598-2625
Practice Address - Fax:870-598-5676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770897076OtherNPI
1083776611OtherNPI