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General NPI Number Information
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NPI Number | 1356730063
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Entity Type | Organization
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Legal Business Name | CUSTOMEYES VISION CARE OF TRUMANN, INC
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Dates
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Enumeration Date | 01/19/2015
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Last Update Date | 01/19/2015
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Provider Practice Location Address
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Address Line | 807 W MAIN ST
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City | TRUMANN
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State | AR
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Zip | 72472-2611
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Country | US
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Telephone | 870-483-0096
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Fax |
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Provider Business Mailing Address
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Address Line | 807 W MAIN ST
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City | TRUMANN
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State | AR
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Zip | 72472-2611
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Country | US
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Telephone | 870-483-0096
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Fax |
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Authorized Official
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Title or Position | OWNER/OPTOMETRIC PHYSICIAN
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Name | DR. GAVIN TRENT MCDOWELL
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Credential | O.D.
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Telephone | 870-483-0096
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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 | 2630
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2577
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License Number State | AR
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