Healthcare Provider Details

I. General information

NPI: 1902898547
Provider Name (Legal Business Name): GRANT C AMSTUTZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 BOBBY BLAND WAY
LEITCHFIELD KY
42754-1744
US

IV. Provider business mailing address

31 BOBBY BLAND WAY
LEITCHFIELD KY
42754-1744
US

V. Phone/Fax

Practice location:
  • Phone: 270-259-0500
  • Fax: 270-259-0079
Mailing address:
  • Phone: 270-259-0500
  • Fax: 270-259-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003059A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: