Healthcare Provider Details

I. General information

NPI: 1659998524
Provider Name (Legal Business Name): PCD MANAGEMENT OF PADUCAH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 JORDAN DRIVE SUITE 101
PADUCAH KY
42001
US

IV. Provider business mailing address

5312 W 41ST ST
TULSA OK
74107-6110
US

V. Phone/Fax

Practice location:
  • Phone: 270-297-2020
  • Fax:
Mailing address:
  • Phone: 918-895-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: CALEB TANCK
Title or Position: CREDENTIALING AGENT
Credential:
Phone: 539-476-2015