Healthcare Provider Details

I. General information

NPI: 1033110291
Provider Name (Legal Business Name): MAR-TAN FAMILY VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 GERI LN
RICHMOND KY
40475-2359
US

IV. Provider business mailing address

205 GERI LN
RICHMOND KY
40475-2359
US

V. Phone/Fax

Practice location:
  • Phone: 859-623-4267
  • Fax: 859-623-4249
Mailing address:
  • Phone: 859-623-4267
  • Fax: 859-623-4249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberKY325
License Number StateKY

VIII. Authorized Official

Name: MR. JIMMIE T PHELPS
Title or Position: OWNER / OPTICIAN
Credential:
Phone: 859-623-4267