Healthcare Provider Details

I. General information

NPI: 1821089640
Provider Name (Legal Business Name): OAK TREE EYE CLINIC INC PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WEST EVERLY BROTHERS BLVD
CENTRAL CITY KY
42330-0676
US

IV. Provider business mailing address

1601 WEST EVERLY BROTHERS BLVD
CENTRAL CITY KY
42330-0676
US

V. Phone/Fax

Practice location:
  • Phone: 270-754-4515
  • Fax: 270-754-2547
Mailing address:
  • Phone: 270-754-4515
  • Fax: 270-754-2547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. FREDDIE M MAYES
Title or Position: PRESIDENT
Credential:
Phone: 270-754-4515