Healthcare Provider Details

I. General information

NPI: 1962793976
Provider Name (Legal Business Name): KSM, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 OLD ROSEBUD RD SUITE 130
LEXINGTON KY
40509-8008
US

IV. Provider business mailing address

2716 OLD ROSEBUD RD SUITE 130
LEXINGTON KY
40509-8008
US

V. Phone/Fax

Practice location:
  • Phone: 859-327-3701
  • Fax:
Mailing address:
  • Phone: 859-327-3701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: KAREN SANTOS MCCLOUD
Title or Position: SOLE MEMBER
Credential: O.D.
Phone: 859-327-3701