Healthcare Provider Details

I. General information

NPI: 1063837847
Provider Name (Legal Business Name): RICK RAKOTZ OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N DEVILS DEN RD
WINSLOW AR
72959-2605
US

IV. Provider business mailing address

1400 N DEVILS DEN RD
WINSLOW AR
72959-2605
US

V. Phone/Fax

Practice location:
  • Phone: 479-530-3825
  • Fax:
Mailing address:
  • Phone: 479-530-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberL-030453
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: