=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952532681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOT SPRINGS VISIONSOURCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2009
-----------------------------------------------------
Last Update Date | 10/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 SECTION LINE
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-525-2222
-----------------------------------------------------
Fax | 501-525-8650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 SECTION LINE
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-525-2222
-----------------------------------------------------
Fax | 501-525-8650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DALE BURROUGHS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 501-525-2222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2308
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------