Healthcare Provider Details

I. General information

NPI: 1790779676
Provider Name (Legal Business Name): STACEY DELANE RAINES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 ALEXANDER DR SUITE E
JONESBORO AR
72401-7070
US

IV. Provider business mailing address

PO BOX 17287
JONESBORO AR
72403-6723
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-3937
  • Fax: 870-336-3934
Mailing address:
  • Phone: 870-336-3937
  • Fax: 870-336-3934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2454
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: