Provider Demographics
NPI:1780773481
Name:CHRIS DEITRICK OD PA
Entity type:Organization
Organization Name:CHRIS DEITRICK OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-269-3610
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:202 PEABODY
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-1460
Mailing Address - Country:US
Mailing Address - Phone:870-269-3610
Mailing Address - Fax:870-269-5086
Practice Address - Street 1:202 PEABODY ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-1460
Practice Address - Country:US
Practice Address - Phone:870-269-3610
Practice Address - Fax:870-269-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2516152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4709560001Medicare NSC
ARCK7118Medicare PIN
AR5C763Medicare PIN