Healthcare Provider Details

I. General information

NPI: 1821268392
Provider Name (Legal Business Name): CAROL LYNN DEITZ O D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 DUDLEY RD.
EDGEWOOD KY
41017-3296
US

IV. Provider business mailing address

581 DUDLEY RD.
EDGEWOOD KY
41017-3296
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-0888
  • Fax: 859-341-3386
Mailing address:
  • Phone: 859-341-0888
  • Fax: 859-341-3386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1134DT
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1134DT
License Number StateKY

VIII. Authorized Official

Name: SHEILA J KING
Title or Position: MANAGER/OPTICIAN
Credential:
Phone: 859-341-0888