MEDICARE: KY DOCTORS OF OPTOMETRY, PLLC

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1477924884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KY DOCTORS OF OPTOMETRY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 846027
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-6027
Country	:	US
Telephone Number	:	800-340-0129
Fax Number	:	210-524-6587

Provider Business Practice Location Address
First Line	:	4135 FT CAMPBELL BOULEVARD
Second Line	:
City	:	HOPKINSVILLE
State	:	KY
Zip	:	42240-8706
Country	:	US
Telephone Number	:	270-887-5765
Fax Number	:	270-887-5766

Authorized Official
Title or Position	:	OWNER
Name	:	GRANT RUBESH
Credential	:	O.D.
Telephone Number	:	726-444-4078

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	09/11/2024

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