Healthcare Provider Details

I. General information

NPI: 1457412991
Provider Name (Legal Business Name): PETTY AND PETTY, P. A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DAWN DR
CENTERTON AR
72719-9314
US

IV. Provider business mailing address

101 DAWN DR
CENTERTON AR
72719-9314
US

V. Phone/Fax

Practice location:
  • Phone: 479-795-1411
  • Fax: 479-795-1412
Mailing address:
  • Phone: 479-795-1411
  • Fax: 479-795-1412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2567
License Number StateAR

VIII. Authorized Official

Name: DR. REGAN SKYE PETTY
Title or Position: OPTOMETRIST PRESIDENT
Credential: O.D.
Phone: 479-795-1411