1043410822 NPI number — RIVER CITIES EYE CONSULTANT

Table of content: (NPI 1043410822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043410822 NPI number — RIVER CITIES EYE CONSULTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER CITIES EYE CONSULTANT
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:
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:
1043410822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2119 CARTER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-329-2243
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2119 CARTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-7733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-329-2243
Provider Business Practice Location Address Fax Number:
606-324-2395
Provider Enumeration Date:
07/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VALLANCE
Authorized Official First Name:
JENNY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
BILLING COORDINATOR
Authorized Official Telephone Number:
606-329-2243

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X , with the licence number:  41013 , 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: 7673570 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com