=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609546720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL VISION OPTICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2021
-----------------------------------------------------
Last Update Date | 09/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 TRIANGLE ST
-----------------------------------------------------
City | MARTIN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41649-7992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-949-1911
-----------------------------------------------------
Fax | 606-949-1910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 TRIANGLE ST
-----------------------------------------------------
City | MARTIN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41649-7992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-949-1911
-----------------------------------------------------
Fax | 606-949-1910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES KENDALL CECIL
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 606-949-1911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------