MEDICARE: VISION KY IDTF, 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	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1487013066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISION KY IDTF, LLC

Provider Business Mailing Address
First Line	:	3011 HARRAH DR
Second Line	:	SUITE L
City	:	SPRING HILL
State	:	TN
Zip	:	37174-6252
Country	:	US
Telephone Number	:	423-480-4087
Fax Number	:

Provider Business Practice Location Address
First Line	:	7321 NEW LA GRANGE RD
Second Line	:	SUITE 112
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-4800
Country	:	US
Telephone Number	:	828-242-0640
Fax Number	:

Authorized Official
Title or Position	:	CORPORATE BUSINESS DEVELOPMENT
Name	:	AMY BROOKMAN
Credential	:
Telephone Number	:	423-480-4087

Provider Enumeration Date	:	02/11/2016
Last Update Date	:	03/02/2016

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