Provider Demographics
NPI:1194215764
Name:OPTICOUTURE LLC
Entity Type:Organization
Organization Name:OPTICOUTURE LLC
Other - Org Name:OPTICOUTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:SHOATS
Authorized Official - Suffix:JR
Authorized Official - Credentials:ABOC
Authorized Official - Phone:502-966-7864
Mailing Address - Street 1:4201 WOODED WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-1537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:959 VINE STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2071
Practice Address - Country:US
Practice Address - Phone:502-966-7864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163667332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier