Healthcare Provider Details

I. General information

NPI: 1497936256
Provider Name (Legal Business Name): MCCLOUD EYE CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E MAIN ST
GRAYSON KY
41143-1301
US

IV. Provider business mailing address

107 E MAIN ST
GRAYSON KY
41143-1301
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-5149
  • Fax: 606-474-0648
Mailing address:
  • Phone: 606-474-5149
  • Fax: 606-474-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1585DT
License Number StateKY

VIII. Authorized Official

Name: DR. JASON H MCCLOUD
Title or Position: OPTOMETRIST
Credential: OD
Phone: 606-474-5149