=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255415410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KY DOCTORS OF OPTOMETRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2312 SIR BARTON WAY SUITE 170
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-543-8383
-----------------------------------------------------
Fax | 859-264-9734
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 846027
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-6027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-524-6663
-----------------------------------------------------
Fax | 210-524-6587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GRANT RUBESH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 726-444-4078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------