Healthcare Provider Details

I. General information

NPI: 1114224201
Provider Name (Legal Business Name): VANCE VISION CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W MAIN ST SUITE 4
COTTER AR
72626-9777
US

IV. Provider business mailing address

1200 W MAIN ST SUITE 4
COTTER AR
72626-9777
US

V. Phone/Fax

Practice location:
  • Phone: 870-435-3333
  • Fax: 870-435-1333
Mailing address:
  • Phone: 870-435-3333
  • Fax: 870-435-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2657
License Number StateAR

VIII. Authorized Official

Name: DR. DUSTIN C VANCE
Title or Position: OWNER/DOCTOR
Credential: O.D.
Phone: 573-382-2974