Healthcare Provider Details

I. General information

NPI: 1639203474
Provider Name (Legal Business Name): PROFESSIONAL EYECARE, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 COURT ST
PAINTSVILLE KY
41240-1051
US

IV. Provider business mailing address

341 COURT ST
PAINTSVILLE KY
41240-1051
US

V. Phone/Fax

Practice location:
  • Phone: 606-789-4675
  • Fax: 606-789-3262
Mailing address:
  • Phone: 606-789-4675
  • Fax: 606-789-3262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL MANN
Title or Position: OWNER
Credential: OD
Phone: 606-789-4675