Provider Demographics
NPI:1013584648
Name:LE CLAIR'S OPTICAL, PSC
Entity Type:Organization
Organization Name:LE CLAIR'S OPTICAL, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-351-5367
Mailing Address - Street 1:171 E LINCOLN TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1253
Mailing Address - Country:US
Mailing Address - Phone:270-351-5367
Mailing Address - Fax:270-319-4929
Practice Address - Street 1:171 E LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-1253
Practice Address - Country:US
Practice Address - Phone:270-351-5367
Practice Address - Fax:270-319-4929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY108328OtherKENTUCKY SALES & USE TAX ACCOUNT