1760701635 NPI number — SOUTH CREEK EYE CENTER PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760701635 NPI number — SOUTH CREEK EYE CENTER PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CREEK EYE CENTER 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:
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:
1760701635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 280
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITLEY CITY
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42653-0280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-376-4199
Provider Business Mailing Address Fax Number:
606-376-9693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 N HWY. 27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITLEY CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-376-4199
Provider Business Practice Location Address Fax Number:
606-376-9693
Provider Enumeration Date:
05/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NASER
Authorized Official First Name:
MAHMUD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-376-4199

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  31817 , 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: 64318173 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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