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General NPI Number Information
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NPI Number | 1518054055
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Entity Type | Organization
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Legal Business Name | SOUTHERN EYE ASSOCIATES
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 06/11/2010
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Provider Practice Location Address
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Address Line | 609 N MISSOURI AVE
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City | CORNING
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State | AR
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Zip | 72422-1617
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Country | US
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Telephone | 870-857-6556
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Fax | 870-857-3787
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Provider Business Mailing Address
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Address Line | PO BOX 37
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City | CORNING
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State | AR
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Zip | 72422-0037
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Country | US
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Telephone | 870-857-6556
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Fax | 870-857-3787
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TRACY L POLLOCK
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Credential |
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Telephone | 870-935-6396
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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 | 2293
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License Number State | AR
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