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General NPI Number Information
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NPI Number | 1053643817
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Entity Type | Individual
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Provider Name | MICKEY LEE DRAKE I OPTICIAN
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Gender | Male
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Dates
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Enumeration Date | 02/04/2010
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Last Update Date | 02/04/2010
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Provider Practice Location Address
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Address Line | 111 PONDEROSA LN SUITE H
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City | HOT SPRINGS VILLAGE
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State | AR
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Zip | 71909-5018
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Country | US
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Telephone | 501-984-5955
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Fax | 501-984-5955
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Provider Business Mailing Address
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Address Line | 111 PONDEROSA LN SUITE H
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City | HOT SPRINGS VILLAGE
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State | AR
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Zip | 71909-5018
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Country | US
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Telephone | 501-984-5955
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Fax | 501-984-5955
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | L-981101
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | L-030454
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License Number State | AR
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