=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487719423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANGEVIN VISION CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 SOUTH COLLEGE STREET
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-425-8899
-----------------------------------------------------
Fax | 870-425-2544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 SOUTH COLLEGE STREET
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-425-8899
-----------------------------------------------------
Fax | 870-425-2544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR OWNER
-----------------------------------------------------
Name | DR. MICHAEL A LANGEVIN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 870-425-8899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2264
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------