Healthcare Provider Details

I. General information

NPI: 1659594109
Provider Name (Legal Business Name): CHILDRENS VISION AND LEARNING CENTER, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 CROSSFIELD DR
VERSAILLES KY
40383-1444
US

IV. Provider business mailing address

105 CROSSFIELD DR
VERSAILLES KY
40383-1444
US

V. Phone/Fax

Practice location:
  • Phone: 859-879-3665
  • Fax: 859-879-3662
Mailing address:
  • Phone: 859-879-3665
  • Fax: 859-879-3662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1044-DT
License Number StateKY

VIII. Authorized Official

Name: RICHARD GRAEBE
Title or Position: OWNER
Credential: O.D.
Phone: 859-879-0089