Healthcare Provider Details

I. General information

NPI: 1871178350
Provider Name (Legal Business Name): IIII OPTICAL BAPTIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 BAPTIST HEALTH DR STE 301
LITTLE ROCK AR
72205-6230
US

IV. Provider business mailing address

3805 W 28TH AVE
PINE BLUFF AR
71603-4774
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-4488
  • Fax: 501-225-9299
Mailing address:
  • Phone: 870-536-4100
  • Fax: 870-534-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: AMY OFFUTT
Title or Position: CONTROLLER
Credential:
Phone: 870-536-4100