Healthcare Provider Details

I. General information

NPI: 1598858300
Provider Name (Legal Business Name): LARRY L. MINIX DBA THE OPTICAL SHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 TAMARACK RD SUITE 100
OWENSBORO KY
42301-6984
US

IV. Provider business mailing address

1115 TAMARACK RD SUITE 100
OWENSBORO KY
42301-6984
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-4933
  • Fax: 270-688-0627
Mailing address:
  • Phone: 270-926-4933
  • Fax: 270-688-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY L. MINIX
Title or Position: OWNER
Credential: OPTICIAN HIS
Phone: 270-926-4933