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General NPI Number Information
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NPI Number | 1700195443
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Entity Type | Organization
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Legal Business Name | SCK VISION CARE PSC
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Dates
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Enumeration Date | 09/29/2010
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Last Update Date | 09/29/2010
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Provider Practice Location Address
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Address Line | 105 MOHAWK ST
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City | BROWNSVILLE
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State | KY
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Zip | 42210-8544
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Country | US
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Telephone | 270-597-2333
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Fax | 270-597-2333
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Provider Business Mailing Address
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Address Line | PO BOX 124
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City | BROWNSVILLE
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State | KY
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Zip | 42210-0124
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Country | US
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Telephone | 270-597-2333
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Fax | 270-597-2333
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JARROD ASHLEY MAYHEW
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Credential | O.D.
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Telephone | 270-597-2333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1461DT
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License Number State | KY
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