Provider Demographics
NPI:1184683609
Name:OWENSBORO FAMILY EYE CARE CENTER PSC
Entity Type:Organization
Organization Name:OWENSBORO FAMILY EYE CARE CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-683-2101
Mailing Address - Street 1:3310 PROFESSIONAL PARK DR.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-683-2101
Mailing Address - Fax:270-683-2507
Practice Address - Street 1:3310 PROFESSIONAL PARK DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-683-2101
Practice Address - Fax:270-683-2507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903599Medicaid
KY77903599Medicaid