Basic Information
| Provider Information | |||||||||
| NPI: | 1043352792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKELL | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | KENTON | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 414721029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067432554 | ||||||||
| FaxNumber: | 6067432018 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 414721014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067434111 | ||||||||
| FaxNumber: | 6067432018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1035DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77010353 | 05 | KY | MEDICAID | 3859 | 01 | KY | CHA | OTHER | 000000068235 | 01 | KY | BLUECROSSBLUESHIELD | OTHER |