=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982121570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAVERICK OPTICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1937 OLD MAIN ST STE 2
-----------------------------------------------------
City | MAYSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41056-8956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-759-7311
-----------------------------------------------------
Fax | 606-759-0610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1937 OLD MAIN ST STE 2
-----------------------------------------------------
City | MAYSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41056-8956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-759-7311
-----------------------------------------------------
Fax | 606-759-0610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASST
-----------------------------------------------------
Name | JOYCE PECK
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 606-564-8794
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 110718
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 110718
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------