Provider Demographics
NPI:1447330659
Name:COMMUNITY VISION CENTER MOSSCO INC DR RANDY WAYNE MOSS OD
Entity type:Organization
Organization Name:COMMUNITY VISION CENTER MOSSCO INC DR RANDY WAYNE MOSS OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-246-6877
Mailing Address - Street 1:109 WP MALONE
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923
Mailing Address - Country:US
Mailing Address - Phone:870-246-6877
Mailing Address - Fax:870-245-0088
Practice Address - Street 1:109 WP MALONE
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923
Practice Address - Country:US
Practice Address - Phone:870-246-6877
Practice Address - Fax:870-245-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2140152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
48222OtherBLUE CROSS BLUE SHIELD
AR48222Medicare UPIN
AROPT000Medicare PIN