Basic Information
| Provider Information | |||||||||
| NPI: | 1669486528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN EYE ASSOCIATES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E MATTHEWS AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709356396 | ||||||||
| FaxNumber: | 8709354063 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E MATTHEWS AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709356396 | ||||||||
| FaxNumber: | 8709354063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHRONISTER | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8709356396 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MC-1284 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | MC-1284 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 116840002 | 05 | AR | MEDICAID | 503329807 | 01 | MO | MISSOURI MEDICAID | OTHER | CT1713 | 01 | AR | RAILROAD MEDICARE | OTHER |