Healthcare Provider Details

I. General information

NPI: 1033295639
Provider Name (Legal Business Name): CHARLES TODD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 LOCUST ST
CONWAY AR
72034-5325
US

IV. Provider business mailing address

552 LOCUST ST
CONWAY AR
72034-5325
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-6859
  • Fax: 501-329-6850
Mailing address:
  • Phone: 501-329-6859
  • Fax: 501-329-6850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2476
License Number StateAR

VIII. Authorized Official

Name: CHARLES TODD
Title or Position: OWNER
Credential: O.D.
Phone: 501-329-6859