Provider Demographics
NPI:1063680304
Name:BLUEGRASS EYECARE CENTER, PLLC
Entity Type:Organization
Organization Name:BLUEGRASS EYECARE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:W DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-278-8443
Mailing Address - Street 1:715 SHAKER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3674
Mailing Address - Country:US
Mailing Address - Phone:859-278-8443
Mailing Address - Fax:
Practice Address - Street 1:715 SHAKER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3674
Practice Address - Country:US
Practice Address - Phone:859-278-8443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
KY21381207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00599OtherMEDICARE GROUP NUMBER
KY7100030920Medicaid
KY6107120001Medicare NSC