=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811030075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS DUVALL TADE AND ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2625 SCOTTSVILLE RD STE 324
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-6379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-846-0131
-----------------------------------------------------
Fax | 270-846-2231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2625 SCOTTSVILLE RD STE 324
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-6379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-846-0131
-----------------------------------------------------
Fax | 270-846-2231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. ROBERT BURLIEN DUVALL
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 270-846-0131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | KY1314
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------