=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427540152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEDOM EYE CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2018
-----------------------------------------------------
Last Update Date | 05/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 SE CLUB BLVD
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-5182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-636-4300
-----------------------------------------------------
Fax | 479-636-4434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 SE CLUB BLVD
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-5182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-636-4300
-----------------------------------------------------
Fax | 479-636-4434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN BRETT MILLS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 479-636-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | AR2477
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------