Basic Information
Provider Information | |||||||||
NPI: | 1093735912 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENTUCKY INSTITUTE FOR EYE HEALTH & SURGERY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KENTUCKY EYE INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1401 HARRODSBURG RD | ||||||||
Address2: | B-75 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405041724 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1800432927 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 975 S LAUREL RD STE B | ||||||||
Address2: |   | ||||||||
City: | LONDON | ||||||||
State: | KY | ||||||||
PostalCode: | 407447862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6068782020 | ||||||||
FaxNumber: | 6068782055 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 05/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MYERS | ||||||||
AuthorizedOfficialFirstName: | ARIC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8592789393 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 152W00000X | KY1384DT | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 77013845 | 05 | KY |   | MEDICAID |