Provider Demographics
NPI:1124170360
Name:KILGORE VISION CENTER
Entity type:Organization
Organization Name:KILGORE VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIKANEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-741-1910
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0444
Mailing Address - Country:US
Mailing Address - Phone:870-424-4900
Mailing Address - Fax:
Practice Address - Street 1:105 SAWGRASS PT
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3072
Practice Address - Country:US
Practice Address - Phone:870-741-1910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1124170360OtherPTAN
AR0796210002Medicare NSC
AR1124170360OtherPTAN