Provider Demographics
NPI:1457412991
Name:PETTY AND PETTY, P. A.
Entity Type:Organization
Organization Name:PETTY AND PETTY, P. A.
Other - Org Name:CENTERTON FAMILY EYECARE, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGAN
Authorized Official - Middle Name:SKYE
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-795-1411
Mailing Address - Street 1:101 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9314
Mailing Address - Country:US
Mailing Address - Phone:479-795-1411
Mailing Address - Fax:479-795-1412
Practice Address - Street 1:101 DAWN DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9314
Practice Address - Country:US
Practice Address - Phone:479-795-1411
Practice Address - Fax:479-795-1412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARV07812Medicare UPIN
ARV07874Medicare UPIN
AR6040140001Medicare NSC
AR49935Medicare ID - Type Unspecified
ARDT6109Medicare PIN
AR49934Medicare ID - Type Unspecified