1114128667 NPI number — ROGER D. FANNIN, OD, PSC

Table of content: (NPI 1114128667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114128667 NPI number — ROGER D. FANNIN, OD, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGER D. FANNIN, OD, PSC
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:
FAMILY VISION HEALTH CENTER
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:
1114128667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
313 S CAROL MALONE BLVD
Provider Second Line Business Mailing Address:
PO BOX 485
Provider Business Mailing Address City Name:
GRAYSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41143-1357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-474-7833
Provider Business Mailing Address Fax Number:
606-474-3563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 S CAROL MALONE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAYSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41143-1357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-474-7833
Provider Business Practice Location Address Fax Number:
606-474-3563
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FANNIN
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-474-7833

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1018DT , 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: 77901023 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA4435 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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