Healthcare Provider Details

I. General information

NPI: 1104968510
Provider Name (Legal Business Name): RICHARD W WIKE O D PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 BELLA VISTA WAY
BELLA VISTA AR
72714-3709
US

IV. Provider business mailing address

2829 BELLA VISTA WAY
BELLA VISTA AR
72714-3709
US

V. Phone/Fax

Practice location:
  • Phone: 479-855-0009
  • Fax: 479-876-7105
Mailing address:
  • Phone: 479-855-0009
  • Fax: 479-876-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAR2256
License Number StateAR

VIII. Authorized Official

Name: DR. RICHARD W WIKE
Title or Position: PRESIDENT
Credential: OD
Phone: 479-855-0009