Basic Information
| Provider Information | |||||||||
| NPI: | 1427436682 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENTUCKY INSTITUTE FOR EYE HEALTH & SURGERY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENTUCKY EYE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 PERIMETER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592789393 | ||||||||
| FaxNumber: | 8592780923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1431 E CUMBERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLESBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409651117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062487772 | ||||||||
| FaxNumber: | 6062480575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | JOHANNES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8592789393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.