MEDICARE: EDMONTON FAMILY VISION CENTER PSC

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	1226DT	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275712416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDMONTON FAMILY VISION CENTER PSC

Provider Business Mailing Address
First Line	:	1406 W STOCKTON ST
Second Line	:
City	:	EDMONTON
State	:	KY
Zip	:	42129-8125
Country	:	US
Telephone Number	:	270-432-0123
Fax Number	:	270-432-5899

Provider Business Practice Location Address
First Line	:	1406 W STOCKTON ST
Second Line	:
City	:	EDMONTON
State	:	KY
Zip	:	42129-8125
Country	:	US
Telephone Number	:	270-432-0123
Fax Number	:	270-432-5899

Authorized Official
Title or Position	:	CEO
Name	:	DR. ROBERT N WHITLOW II
Credential	:	O.D.
Telephone Number	:	270-432-0123

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	02/20/2017

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