=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790779676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY DELANE RAINES O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2005
-----------------------------------------------------
Last Update Date | 02/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2704 ALEXANDER DR SUITE E
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-7070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-336-3937
-----------------------------------------------------
Fax | 870-336-3934
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 17287
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72403-6723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-336-3937
-----------------------------------------------------
Fax | 870-336-3934
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2454
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------