Provider Demographics
NPI:1831152800
Name:WALLACE EYE CLINIC OPTICAL SHOP
Entity type:Organization
Organization Name:WALLACE EYE CLINIC OPTICAL SHOP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:NANETTE
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-624-0609
Mailing Address - Street 1:211 MCAULEY CT
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6314
Mailing Address - Country:US
Mailing Address - Phone:501-624-0609
Mailing Address - Fax:501-624-6191
Practice Address - Street 1:211 MCAULEY CT
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6314
Practice Address - Country:US
Practice Address - Phone:501-624-0609
Practice Address - Fax:501-624-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0749110001Medicare NSC