=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275703563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D PAYNE ENTERPRISES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2008
-----------------------------------------------------
Last Update Date | 03/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 N 12TH ST SUITE G
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42071-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-753-5507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 N 12TH ST SUITE G
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42071-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOUGLAS PAYNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-753-5507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | KY 1489 DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------