Healthcare Provider Details

I. General information

NPI: 1508986167
Provider Name (Legal Business Name): CLINIC OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PARK ST
BOWLING GREEN KY
42101-1759
US

IV. Provider business mailing address

201 PARK ST
BOWLING GREEN KY
42101-1759
US

V. Phone/Fax

Practice location:
  • Phone: 270-780-0594
  • Fax: 270-783-3361
Mailing address:
  • Phone: 270-780-0594
  • Fax: 270-783-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License NumberE82360
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number102090
License Number StateKY

VIII. Authorized Official

Name: DR. JENNIFER WENTWORTH
Title or Position: OPHTHALMOLOGIST
Credential: M.D.
Phone: 270-780-0594