Healthcare Provider Details

I. General information

NPI: 1780773481
Provider Name (Legal Business Name): CHRIS DEITRICK OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 PEABODY ST
MOUNTAIN VIEW AR
72560-1460
US

IV. Provider business mailing address

PO BOX 1460 202 PEABODY
MOUNTAIN VIEW AR
72560-1460
US

V. Phone/Fax

Practice location:
  • Phone: 870-269-3610
  • Fax: 870-269-5086
Mailing address:
  • Phone: 870-269-3610
  • Fax: 870-269-5086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2516
License Number StateAR

VIII. Authorized Official

Name: MRS. LANETTE LEE
Title or Position: OFFICE MANAGER
Credential:
Phone: 870-269-3610