Provider Demographics
NPI:1184773020
Name:DR PENNY FRESHOUR OD PA
Entity type:Organization
Organization Name:DR PENNY FRESHOUR OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRESHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-791-0660
Mailing Address - Street 1:3929 MCCAIN BLVD
Mailing Address - Street 2:#G07A
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8011
Mailing Address - Country:US
Mailing Address - Phone:501-791-0660
Mailing Address - Fax:501-753-4401
Practice Address - Street 1:3929 MCCAIN BLVD
Practice Address - Street 2:#G07A
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8011
Practice Address - Country:US
Practice Address - Phone:501-791-0660
Practice Address - Fax:501-753-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR19983000040OtherQUALCHOICE
ARAR2483OtherAR LICENSE
ARP00273197OtherRAILROAD MEDICARE
ARAR2483OtherAR LICENSE
AR49531Medicare ID - Type Unspecified