=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609450055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARSHALL FAMILY EYECARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2021
-----------------------------------------------------
Last Update Date | 07/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 EAST MAIN STREET
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-448-2233
-----------------------------------------------------
Fax | 870-448-5006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1109
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72650-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-448-2233
-----------------------------------------------------
Fax | 870-448-5006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | CARYLENE DOWELL GENTRY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 870-448-7362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------