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General NPI Number Information
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NPI Number | 1063680304
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Entity Type | Organization
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Legal Business Name | BLUEGRASS EYECARE CENTER, PLLC
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Dates
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Enumeration Date | 02/20/2008
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Last Update Date | 09/08/2008
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Provider Practice Location Address
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Address Line | 715 SHAKER DR SUITE 120
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City | LEXINGTON
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State | KY
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Zip | 40504-3674
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Country | US
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Telephone | 859-278-8443
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Fax |
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Provider Business Mailing Address
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Address Line | 715 SHAKER DR SUITE 120
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City | LEXINGTON
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State | KY
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Zip | 40504-3674
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Country | US
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Telephone | 859-278-8443
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Fax |
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Authorized Official
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Title or Position | SECRETARY/MEMBER
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Name | DR. W DOUGLAS BACK
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Credential | M.D.
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Telephone | 859-278-8443
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 21381
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License Number State | KY
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