Healthcare Provider Details

I. General information

NPI: 1558485839
Provider Name (Legal Business Name): FAMILY EYEHEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1824 DECLARATION DR
INDEPENDENCE KY
41051-8196
US

IV. Provider business mailing address

1824 DECLARATION DR
INDEPENDENCE KY
41051-8196
US

V. Phone/Fax

Practice location:
  • Phone: 859-363-3347
  • Fax:
Mailing address:
  • Phone: 859-363-3347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1168DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1168DT
License Number StateKY

VIII. Authorized Official

Name: CRAIG S PENNELL
Title or Position: OWNER
Credential: OD
Phone: 859-363-3347