Provider Demographics
NPI:1053446732
Name:DR. RICKY FERGUSON VISION CENTER PA
Entity type:Organization
Organization Name:DR. RICKY FERGUSON VISION CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-367-8511
Mailing Address - Street 1:408 W MCCLOY ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-4325
Mailing Address - Country:US
Mailing Address - Phone:870-367-8511
Mailing Address - Fax:870-367-3215
Practice Address - Street 1:408 W MCCLOY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4325
Practice Address - Country:US
Practice Address - Phone:870-367-8511
Practice Address - Fax:870-367-3215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR410040927OtherMEDICARE RAILROAD
AR138899722Medicaid
AR410040927OtherMEDICARE RAILROAD
AR138899722Medicaid