Healthcare Provider Details

I. General information

NPI: 1417765488
Provider Name (Legal Business Name): CENTRAL ARKANSAS LASIK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N VAN BUREN ST
LITTLE ROCK AR
72205-3650
US

IV. Provider business mailing address

1900 SHADOW LN
LITTLE ROCK AR
72207-2018
US

V. Phone/Fax

Practice location:
  • Phone: 501-712-5200
  • Fax: 501-353-1221
Mailing address:
  • Phone: 501-554-6112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD M. PENICK III
Title or Position: OPHTHALMOLOGIST/LASIK SURGEON
Credential: M.D.
Phone: 501-712-5200