=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003145319
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY EYE CARE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2009
-----------------------------------------------------
Last Update Date | 01/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 CASH RD SW
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71701-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-836-2525
-----------------------------------------------------
Fax | 870-836-7252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 CASH RD SW
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71701-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-836-2525
-----------------------------------------------------
Fax | 870-836-7252
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JERRY NUTT
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 870-836-2525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2582
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2570
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------