Healthcare Provider Details

I. General information

NPI: 1427513662
Provider Name (Legal Business Name): DHP RETAIL ENTITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 CAMPBELL LN STE 104
BOWLING GREEN KY
42104-1062
US

IV. Provider business mailing address

431 PREAKNESS WAY
BOWLING GREEN KY
42104-8563
US

V. Phone/Fax

Practice location:
  • Phone: 561-275-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JACKIE BENNETT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 561-433-6009