Basic Information
| Provider Information | |||||||||
| NPI: | 1477950269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE CENTERS FOR SIGHT, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593442079 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 SCOTT ST | ||||||||
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| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410112420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593414525 | ||||||||
| FaxNumber: | 8593414993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2014 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | NORDLOH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8593442061 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 77903425 | 05 | KY | MEDICAID | 65925760 | 05 | KY | MEDICAID |