Basic Information
| Provider Information | |||||||||
| NPI: | 1881051191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENTUCKY FAMILY EYECARE PLLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KENTUCKY FAMILY EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 975 S LAUREL RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407447862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068782020 | ||||||||
| FaxNumber: | 6068782055 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 S LAUREL RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407447862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068782020 | ||||||||
| FaxNumber: | 6068782055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2016 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OVERLEY | ||||||||
| AuthorizedOfficialFirstName: | ALISON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6068782020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | KY1384DT | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77013845 | 05 | KY | MEDICAID |