MEDICARE: CENTRAL KENTUCKY EYECARE AND WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1104587591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL KENTUCKY EYECARE AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	3221 SUMMIT SQUARE PL STE 200
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-2655
Country	:	US
Telephone Number	:	859-303-6464
Fax Number	:	859-303-6465

Provider Business Practice Location Address
First Line	:	3221 SUMMIT SQUARE PL STE 200
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-2655
Country	:	US
Telephone Number	:	859-303-6464
Fax Number	:	859-303-6465

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	VELVA HUGHES
Credential	:
Telephone Number	:	859-447-0895

Provider Enumeration Date	:	01/06/2022
Last Update Date	:	01/07/2022

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