Healthcare Provider Details

I. General information

NPI: 1689611949
Provider Name (Legal Business Name): WWR, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S BRADFORD LN
GEORGETOWN KY
40324-2336
US

IV. Provider business mailing address

1299 STANDISH WAY
LEXINGTON KY
40504-2045
US

V. Phone/Fax

Practice location:
  • Phone: 859-321-1029
  • Fax:
Mailing address:
  • Phone: 859-523-3553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1845DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number38932
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number45851
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM W. RICHARDSON II
Title or Position: PRESIDENT
Credential: M.D.
Phone: 859-321-1029