Basic Information
| Provider Information | |||||||||
| NPI: | 1396886610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE CENTERS FOR SIGHT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631662 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452631662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595817120 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595817120 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 06/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | KEMPER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8593442079 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CREDENTIALS CORD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0111751 | 05 | OH | MEDICAID | 77903425 | 05 | KY | MEDICAID | 36000321 | 05 | KY | MEDICAID | 65925760 | 05 | KY | MEDICAID |