Provider Demographics
NPI:1356730063
Name:CUSTOMEYES VISION CARE OF TRUMANN, INC
Entity type:Organization
Organization Name:CUSTOMEYES VISION CARE OF TRUMANN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-483-0096
Mailing Address - Street 1:807 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRUMANN
Mailing Address - State:AR
Mailing Address - Zip Code:72472-2611
Mailing Address - Country:US
Mailing Address - Phone:870-483-0096
Mailing Address - Fax:
Practice Address - Street 1:807 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472-2611
Practice Address - Country:US
Practice Address - Phone:870-483-0096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2630152W00000X
AR2577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49966Medicare PIN
AR267164Medicare PIN