=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508006438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIALTY EYECARE OF SOUTH ARKANSAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2009
-----------------------------------------------------
Last Update Date | 03/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 HIGHWAY 425 S
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71655-4611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-367-8534
-----------------------------------------------------
Fax | 870-367-0264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 HIGHWAY 425 S
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71655-4611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-367-8534
-----------------------------------------------------
Fax | 870-367-0264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SCOTT CAVIN CLAYCOMB
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 870-367-8534
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2158
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | C7907
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------