Healthcare Provider Details

I. General information

NPI: 1285621896
Provider Name (Legal Business Name): DANIEL A TALLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E SHEPARDSON ST
PRINCETON KY
42445-1633
US

IV. Provider business mailing address

PO BOX 683
PRINCETON KY
42445-0683
US

V. Phone/Fax

Practice location:
  • Phone: 270-365-6627
  • Fax: 270-365-7700
Mailing address:
  • Phone: 270-365-6627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number933-DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: