MEDICARE: OAK TREE EYE CLINIC INC PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821089640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAK TREE EYE CLINIC INC PSC

Provider Business Mailing Address
First Line	:	1601 WEST EVERLY BROTHERS BLVD
Second Line	:
City	:	CENTRAL CITY
State	:	KY
Zip	:	42330-0676
Country	:	US
Telephone Number	:	270-754-4515
Fax Number	:	270-754-2547

Provider Business Practice Location Address
First Line	:	1601 WEST EVERLY BROTHERS BLVD
Second Line	:
City	:	CENTRAL CITY
State	:	KY
Zip	:	42330-0676
Country	:	US
Telephone Number	:	270-754-4515
Fax Number	:	270-754-2547

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FREDDIE M MAYES
Credential	:
Telephone Number	:	270-754-4515

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	06/25/2010

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