Healthcare Provider Details

I. General information

NPI: 1467918763
Provider Name (Legal Business Name): MED SOUTHWEST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 05/29/2022
Certification Date: 05/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MORROW ST S
MENA AR
71953-2510
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-4215
  • Fax: 479-394-3455
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SUE HEALEY
Title or Position: SECRETARY
Credential:
Phone: 703-847-8899