Provider Demographics
NPI:1588999767
Name:FAYETTEVILLE EYECARE CLINIC
Entity type:Organization
Organization Name:FAYETTEVILLE EYECARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TASKER
Authorized Official - Middle Name:N
Authorized Official - Last Name:RODMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:501-225-9944
Mailing Address - Street 1:11225 HURON LN STE 200A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1861
Mailing Address - Country:US
Mailing Address - Phone:479-442-8961
Mailing Address - Fax:479-442-6440
Practice Address - Street 1:1915 N GREEN ACRES RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2617
Practice Address - Country:US
Practice Address - Phone:479-442-8961
Practice Address - Fax:479-442-6440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182431722Medicaid
AR5G454Medicare PIN