Provider Demographics
NPI:1194834713
Name:PROFESSIONAL OPTICIANS PSC
Entity Type:Organization
Organization Name:PROFESSIONAL OPTICIANS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOLTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:ABO
Authorized Official - Phone:859-278-5409
Mailing Address - Street 1:165 MOORE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503
Mailing Address - Country:US
Mailing Address - Phone:859-278-5409
Mailing Address - Fax:859-276-3491
Practice Address - Street 1:165 MOORE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503
Practice Address - Country:US
Practice Address - Phone:859-278-5409
Practice Address - Fax:859-276-3491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0366156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000066363OtherANTHEM BCBS
KY14560OtherAVESIS
KY52903663Medicaid
KY52903663Medicaid