1851543656 NPI number — EYEMART FAMILY VISION CARE INC

Table of content: (NPI 1851543656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851543656 NPI number — EYEMART FAMILY VISION CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYEMART FAMILY VISION CARE INC
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:
EYE MART
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:
1851543656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9501 TAYLORSVILLE RD STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSONTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40299-2752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-499-2020
Provider Business Mailing Address Fax Number:
502-499-6747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9501 TAYLORSVILLE RD STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSONTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40299-2752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-499-2020
Provider Business Practice Location Address Fax Number:
502-499-6747
Provider Enumeration Date:
10/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-499-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1071DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 77010718 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77901775 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".