Healthcare Provider Details

I. General information

NPI: 1033178736
Provider Name (Legal Business Name): SHANE E. FORD OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 01/07/2025
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 FOUNTAIN DRIVE
CONWAY AR
72034-3684
US

IV. Provider business mailing address

3005 FOUNTAIN DRIVE
CONWAY AR
72034-3684
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-9851
  • Fax: 501-329-9854
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 NumberPC114
License Number StateAR

VIII. Authorized Official

Name: DR. SHANE FORD
Title or Position: PRESIDENT
Credential: O.D.
Phone: 501-329-9851