=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588648992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGIE MABREY EYE CLINIC, P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2005
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 MAIN ST
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-327-4444
-----------------------------------------------------
Fax | 501-327-3962
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 MAIN ST
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-327-4444
-----------------------------------------------------
Fax | 501-327-3962
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CHERYL LYNN PETERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-327-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------