Healthcare Provider Details

I. General information

NPI: 1982792271
Provider Name (Legal Business Name): CHARLES D KREBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 SAINT MATTHEWS AVE
LOUISVILLE KY
40207-3141
US

IV. Provider business mailing address

129 SAINT MATTHEWS AVE
LOUISVILLE KY
40207-3141
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-1199
  • Fax: 502-897-0180
Mailing address:
  • Phone: 502-897-1199
  • Fax: 502-897-0180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number0372
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: