Basic Information
| Provider Information | |||||||||
| NPI: | 1548302839 | ||||||||
| 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: | 140L HARRODSBURG RD. | ||||||||
| Address2: | STE B 75 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592789393 | ||||||||
| FaxNumber: | 8592773965 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 414721014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067434111 | ||||||||
| FaxNumber: | 6067432018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOODWORTH | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMT,COE | ||||||||
| AuthorizedOfficialTelephone: | 8592789393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1035DT | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77902500 | 05 | KY | MEDICAID |