=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598838385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS FAMILY EYECARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 06/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 MAIN STREET
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-274-3294
-----------------------------------------------------
Fax | 270-274-4811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1303 MAIN STREET
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JONATHAN L. SHREWSBURY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 270-274-3294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0956DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------