Healthcare Provider Details

I. General information

NPI: 1336420082
Provider Name (Legal Business Name): EYECARE ASSOCIATES OF KENTUCKY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 BROADWAY ST
PADUCAH KY
42001-2706
US

IV. Provider business mailing address

1748 BROADWAY ST
PADUCAH KY
42001-2706
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-9904
  • Fax: 270-575-0717
Mailing address:
  • Phone: 270-443-9904
  • Fax: 270-575-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK OWENS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 270-443-9904