Healthcare Provider Details

I. General information

NPI: 1457577256
Provider Name (Legal Business Name): HURST EYE CARE CENTER, PA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 SE 14TH ST
BENTONVILLE AR
72712-6812
US

IV. Provider business mailing address

1412 SE 14TH ST
BENTONVILLE AR
72712-6812
US

V. Phone/Fax

Practice location:
  • Phone: 479-271-9700
  • Fax: 479-271-9771
Mailing address:
  • Phone: 479-271-9700
  • Fax: 479-271-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2448
License Number StateAR

VIII. Authorized Official

Name: MS. TONI DIANE MCCULLOUGH
Title or Position: BENEFITS COORDINATOR
Credential:
Phone: 479-271-9700