Healthcare Provider Details

I. General information

NPI: 1609877083
Provider Name (Legal Business Name): JOHN KENYON EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WALL ST
JEFFERSONVILLE IN
47130-3853
US

IV. Provider business mailing address

1305 WALL ST
JEFFERSONVILLE IN
47130-3853
US

V. Phone/Fax

Practice location:
  • Phone: 812-288-9011
  • Fax: 812-288-7479
Mailing address:
  • Phone: 812-288-9011
  • Fax: 812-288-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number15811
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01025213
License Number StateIN

VIII. Authorized Official

Name: MS. SHELLEY RENEE GAST
Title or Position: CONTROLLER
Credential:
Phone: 812-258-3026