Healthcare Provider Details

I. General information

NPI: 1003809849
Provider Name (Legal Business Name): LOWELL CHARLES WARE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

952 FAIRVIEW AVE
BOWLING GREEN KY
42101-4969
US

IV. Provider business mailing address

952 FAIRVIEW AVE
BOWLING GREEN KY
42101-4938
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-2220
  • Fax: 270-781-2155
Mailing address:
  • Phone: 270-781-2220
  • Fax: 270-781-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1255DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: