Healthcare Provider Details

I. General information

NPI: 1851443394
Provider Name (Legal Business Name): SOUTHEASTERN EYE CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21937 MAIN ST.
HYDEN KY
41749
US

IV. Provider business mailing address

21937 MAIN STREET PO DRW 778
HYDEN KY
41749-0778
US

V. Phone/Fax

Practice location:
  • Phone: 606-672-2040
  • Fax: 606-672-3937
Mailing address:
  • Phone: 606-672-2040
  • Fax: 606-672-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0902DT
License Number StateKY

VIII. Authorized Official

Name: MRS. CAROL JO HOLBROOK
Title or Position: OFF MGR
Credential:
Phone: 606-672-2040