=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689697864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ALYCE AUSTIN O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 571 W MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-6404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-527-0100
-----------------------------------------------------
Fax | 479-527-0102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 571 W MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-6404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-527-0100
-----------------------------------------------------
Fax | 479-527-0102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2572
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------