Healthcare Provider Details

I. General information

NPI: 1124170360
Provider Name (Legal Business Name): KILGORE VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SAWGRASS PT
HARRISON AR
72601-3072
US

IV. Provider business mailing address

PO BOX 444
MOUNTAIN HOME AR
72654-0444
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-1910
  • Fax:
Mailing address:
  • Phone: 870-424-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. TINA CIKANEK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 870-741-1910