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General NPI Number Information
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NPI Number | 1295356186
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Entity Type | Individual
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Provider Name | BROCK HELFRICH STUDENT
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Gender | Male
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Dates
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Enumeration Date | 05/01/2020
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Last Update Date | 07/28/2020
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Provider Practice Location Address
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Address Line | 1100 N COLLEGE AVE
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-1999
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Country | US
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Telephone | 479-443-4301
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Fax |
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Provider Business Mailing Address
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Address Line | 314 YORK ST
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City | TAHLEQUAH
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State | OK
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Zip | 74464-2239
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Country | US
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Telephone | 620-682-5726
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Fax |
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3075
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License Number State | OK
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