1427041037 NPI number — JOYCE C PECK

Table of content: JOYCE C PECK (NPI 1427041037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427041037 NPI number — JOYCE C PECK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PECK
Provider First Name:
JOYCE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OPTICAL
Provider Other First Name:
MAVERICK OPTICAL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427041037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41096-0054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-564-8794
Provider Business Mailing Address Fax Number:
606-759-0610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1937 OLD MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MAYSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41056-8956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-759-7311
Provider Business Practice Location Address Fax Number:
606-759-0610
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  111468 , 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: 1063563104 . This is a "EMPLOYEE - IP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1093159626 . This is a "NPI-ADAM BRADLEY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100022560 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5200015500 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60537045 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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