MEDICARE: EYECARE CENTER OPTOMETRIST 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	1069DT	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	:	1427244979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE CENTER OPTOMETRIST PSC

Provider Business Mailing Address
First Line	:	1020 GIBSON BAY DR
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-3448
Country	:	US
Telephone Number	:	859-623-3358
Fax Number	:	859-623-8141

Provider Business Practice Location Address
First Line	:	1073 BROADWAY ST
Second Line	:
City	:	BEATTYVILLE
State	:	KY
Zip	:	41311-8719
Country	:	US
Telephone Number	:	606-464-8148
Fax Number	:	606-464-0142

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM T REYNOLDS JR.
Credential	:	OD
Telephone Number	:	859-623-3358

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	11/10/2008

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