=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205941135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. J PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1461 E HIGHWAY 90 BYP
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42633-2327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-340-9541
-----------------------------------------------------
Fax | 606-677-6542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 RIDGEWOOD AVE
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42633-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-340-9541
-----------------------------------------------------
Fax | 606-677-6542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. JOSHUA ERIC NICHOLS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 606-340-9541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1552DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------