Provider Demographics
NPI:1033110291
Name:MAR-TAN FAMILY VISION CENTER
Entity Type:Organization
Organization Name:MAR-TAN FAMILY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-623-4267
Mailing Address - Street 1:205 GERI LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2359
Mailing Address - Country:US
Mailing Address - Phone:859-623-4267
Mailing Address - Fax:859-623-4249
Practice Address - Street 1:205 GERI LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2359
Practice Address - Country:US
Practice Address - Phone:859-623-4267
Practice Address - Fax:859-623-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY325156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY32646OtherCVC
KY52903259Medicaid
KY260155886OtherTRICARE
KY52800919Medicaid
KY000000195501OtherANTHEM
KY1188575OtherCHA
KY2537729OtherCIGNA
KYOP0933OtherEYEMED
KY1141OtherPVC
KY000000195501OtherANTHEM