Healthcare Provider Details

I. General information

NPI: 1053615286
Provider Name (Legal Business Name): COMMUNITY VISION THERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 WASHINGTON ST
SHELBYVILLE KY
40065-1127
US

IV. Provider business mailing address

403 WASHINGTON ST
SHELBYVILLE KY
40065-1127
US

V. Phone/Fax

Practice location:
  • Phone: 502-647-3937
  • Fax:
Mailing address:
  • Phone: 502-647-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1301DT
License Number StateKY

VIII. Authorized Official

Name: DR. DANIEL M BOWERSOX
Title or Position: OWNER
Credential: OD
Phone: 502-647-3937