Provider Demographics
NPI:1447435698
Name:JUSTUS VISION CENTER P.A.
Entity type:Organization
Organization Name:JUSTUS VISION CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-332-6262
Mailing Address - Street 1:1023 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-5222
Mailing Address - Country:US
Mailing Address - Phone:501-332-6262
Mailing Address - Fax:501-337-0373
Practice Address - Street 1:1023 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-5222
Practice Address - Country:US
Practice Address - Phone:501-332-6262
Practice Address - Fax:501-337-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0396990001Medicare NSC