Healthcare Provider Details

I. General information

NPI: 1740644947
Provider Name (Legal Business Name): KY DOCTORS OF OPTOMETRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CONNECTOR RD
GEORGETOWN KY
40324-9729
US

IV. Provider business mailing address

175 E HOUSTON ST
SAN ANTONIO TX
78205-2255
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-9870
  • Fax: 502-868-5432
Mailing address:
  • Phone: 726-444-4069
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: GRANT RUBESH
Title or Position: OWNER
Credential:
Phone: 726-444-4078