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General NPI Number Information
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NPI Number | 1609071679
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Entity Type | Organization
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Legal Business Name | SOUTH EAST EYECARE PSC
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Dates
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Enumeration Date | 06/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1707 FALLS ROAD PLAZA SUITE U-4
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City | CORBIN
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State | KY
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Zip | 40701
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Country | US
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Telephone | 606-528-7336
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Fax | 606-523-9189
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Provider Business Mailing Address
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Address Line | 1707 FALLS ROAD PLAZA SUITE U-4
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City | CORBIN
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State | KY
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Zip | 40701
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Country | US
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Telephone | 606-528-7336
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Fax | 606-523-9189
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Authorized Official
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Title or Position | OPTICIAN
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Name | MRS. LISA A NICHOLAS
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Credential | ABOC
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Telephone | 606-528-7336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 165742
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License Number State | KY
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