=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306443163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEMAX2020
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 10/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3070 HARRODSBURG RD STE 130
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-312-2793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 DEERFIELD CIR
-----------------------------------------------------
City | NICHOLASVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40356-8043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-312-2793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KARI CARPENTER MATTSON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 859-312-2793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------