Provider Demographics
NPI:1952532681
Name:HOT SPRINGS VISIONSOURCE LLC
Entity Type:Organization
Organization Name:HOT SPRINGS VISIONSOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROUGHS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-525-2222
Mailing Address - Street 1:305 SECTION LINE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913
Mailing Address - Country:US
Mailing Address - Phone:501-525-2222
Mailing Address - Fax:501-525-8650
Practice Address - Street 1:305 SECTION LINE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:501-525-2222
Practice Address - Fax:501-525-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G350Medicare PIN
AR6318900001Medicare NSC