Healthcare Provider Details

I. General information

NPI: 1154740686
Provider Name (Legal Business Name): THU VAN OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 SKYLINE DR
CONWAY AR
72032-2857
US

IV. Provider business mailing address

7420 PALM BEACH AVE
BENTON AR
72019-2023
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-2020
  • Fax: 501-329-2021
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2587
License Number StateAR

VIII. Authorized Official

Name: JUSTIN DANG
Title or Position: MANAGER
Credential:
Phone: 501-329-2020