Healthcare Provider Details

I. General information

NPI: 1437213519
Provider Name (Legal Business Name): LINDA DARLENE GILLIAM LICENSED OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 E NEW CIRCLE RD SUITE 146
LEXINGTON KY
40509-1043
US

IV. Provider business mailing address

1555 E NEW CIRCLE RD SUITE 146
LEXINGTON KY
40509-1043
US

V. Phone/Fax

Practice location:
  • Phone: 859-266-3003
  • Fax: 859-266-9504
Mailing address:
  • Phone: 859-266-3003
  • Fax: 859-266-9504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1069
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: