Healthcare Provider Details

I. General information

NPI: 1710790316
Provider Name (Legal Business Name): SHANE E. FORD OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 HWY. 64 S. SUITE 104
CLINTON AR
72031
US

IV. Provider business mailing address

3005 FOUNTAIN DR
CONWAY AR
72034-3684
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-2500
  • Fax: 501-745-7772
Mailing address:
  • Phone: 501-329-9851
  • Fax: 501-329-9854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: KRISTI ANN BARTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-329-9851