=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003908849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PECK OPTICIANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 370 LONGVIEW DRIVE
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-276-2573
-----------------------------------------------------
Fax | 859-276-2574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 370 LONGVIEW DRIVE
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-276-2573
-----------------------------------------------------
Fax | 859-276-2574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OPTICIAN
-----------------------------------------------------
Name | MR. DENNIS PAUL PECK
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 859-276-2573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 314
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------