Healthcare Provider Details

I. General information

NPI: 1235129776
Provider Name (Legal Business Name): DONNA DAVIS OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 BRAVO BLVD
GLASGOW KY
42141-3478
US

IV. Provider business mailing address

1507 BRAVO BLVD
GLASGOW KY
42141-3478
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-2181
  • Fax: 270-651-2183
Mailing address:
  • Phone: 270-651-2181
  • Fax: 270-651-2183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number451
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: