Healthcare Provider Details

I. General information

NPI: 1083775878
Provider Name (Legal Business Name): PUCKETT FAMILY EYE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 HOSPITAL DR STE 160
WINCHESTER KY
40391-7635
US

IV. Provider business mailing address

225 HOSPITAL DR STE 160
WINCHESTER KY
40391-7635
US

V. Phone/Fax

Practice location:
  • Phone: 859-744-4429
  • Fax: 859-744-3941
Mailing address:
  • Phone: 859-744-4429
  • Fax: 859-745-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1190DT
License Number StateKY

VIII. Authorized Official

Name: RANDALL K PUCKETT
Title or Position: PRESIDENT
Credential: OD
Phone: 859-744-4429