=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326242710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESCRIPTION LENS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 S CHURCH ST
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-972-1818
-----------------------------------------------------
Fax | 870-972-0356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 S CHURCH ST
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-972-1818
-----------------------------------------------------
Fax | 870-972-0356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. RUSTY ACEBO
-----------------------------------------------------
Credential | ABOC
-----------------------------------------------------
Telephone | 870-972-1818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 25089
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------