Healthcare Provider Details

I. General information

NPI: 1003605114
Provider Name (Legal Business Name): BROOKE RADCLIFFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 ALEXANDRIA PIKE
FORT THOMAS KY
41075-1729
US

IV. Provider business mailing address

92 ALEXANDRIA PIKE
FORT THOMAS KY
41075-1729
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-2000
  • Fax: 859-781-8122
Mailing address:
  • Phone: 859-781-2000
  • Fax: 859-781-8122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2455DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: