1275617276 NPI number — TRI-STATE DOCTORS OF

Table of content: (NPI 1275617276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275617276 NPI number — TRI-STATE DOCTORS OF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE DOCTORS OF
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KY DOCTORS OF OPTOMETRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275617276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
726-444-4069
Provider Business Mailing Address Fax Number:
210-524-6587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4655 OUTER LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40219-3970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-966-2020
Provider Business Practice Location Address Fax Number:
502-966-2099
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUBESH
Authorized Official First Name:
GRANT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-750-8384

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7790293000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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