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General NPI Number Information
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NPI Number | 1194215764
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Entity Type | Organization
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Legal Business Name | OPTICOUTURE LLC
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Dates
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Enumeration Date | 05/18/2018
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Last Update Date | 05/18/2018
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Provider Practice Location Address
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Address Line | 959 VINE STREET
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City | LOUISVILLE
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State | KY
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Zip | 40204-2071
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Country | US
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Telephone | 502-966-7864
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Fax |
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Provider Business Mailing Address
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Address Line | 4201 WOODED WAY
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City | LOUISVILLE
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State | KY
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Zip | 40219-1537
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FOUNDER AND CEO
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Name | MR. KENNETH ANTONIO SHOATS JR.
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Credential | ABOC
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Telephone | 502-966-7864
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 163667
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License Number State | KY
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