Healthcare Provider Details

I. General information

NPI: 1588666499
Provider Name (Legal Business Name): REGAN SKYE PETTY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DAWN DR
CENTERTON AR
72719
US

IV. Provider business mailing address

101 DAWN DR
CENTERTON AR
72719-9314
US

V. Phone/Fax

Practice location:
  • Phone: 479-426-1660
  • Fax:
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:
Title or Position:
Credential:
Phone: