Basic Information
Provider Information | |||||||||
NPI: | 1477924884 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KY DOCTORS OF OPTOMETRY, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VISIONWORKS DOCTORS OF OPTOMETRUY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 846027 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752846027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003400129 | ||||||||
FaxNumber: | 2105246587 | ||||||||
Practice Location | |||||||||
Address1: | 4135 FT CAMPBELL BOULEVARD | ||||||||
Address2: |   | ||||||||
City: | HOPKINSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 422408706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708875765 | ||||||||
FaxNumber: | 2708875766 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2015 | ||||||||
LastUpdateDate: | 01/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUBESH | ||||||||
AuthorizedOfficialFirstName: | GRANT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7264444078 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: | 01/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.