1790759884 NPI number — GADDIE EYE CENTERS, LLC

Table of content: CLARA LIVINGSTON CMSRN, PCCN (NPI 1417885393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790759884 NPI number — GADDIE EYE CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GADDIE EYE CENTERS, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1790759884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7635 SHELBYVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-5409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-423-8500
Provider Business Mailing Address Fax Number:
502-339-0571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7635 SHELBYVILLE RD
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:
40222-5409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-423-8500
Provider Business Practice Location Address Fax Number:
502-339-0571
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GADDIE
Authorized Official First Name:
IAN
Authorized Official Middle Name:
BEN
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
502-423-8500

Provider Taxonomy Codes

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

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

  • Identifier: CE7398 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CI8844 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 77901213 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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