Basic Information
| Provider Information | |||||||||
| NPI: | 1871178350 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IIII OPTICAL BAPTIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 W 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716034774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705364100 | ||||||||
| FaxNumber: | 8705343982 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 BAPTIST HEALTH DR STE 301 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012254488 | ||||||||
| FaxNumber: | 5012259299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2021 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | OFFUTT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8705364100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.