Provider Demographics
NPI:1225107014
Name:COMMONWEALTH EYE CLINIC INC
Entity Type:Organization
Organization Name:COMMONWEALTH EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-224-2655
Mailing Address - Street 1:2353 ALEXANDRIA DR
Mailing Address - Street 2:SUITE 325
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3264
Mailing Address - Country:US
Mailing Address - Phone:859-224-2655
Mailing Address - Fax:
Practice Address - Street 1:2353 ALEXANDRIA DR
Practice Address - Street 2:SUITE 325
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3264
Practice Address - Country:US
Practice Address - Phone:859-224-2655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
KY300137261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36001121Medicaid
KYASC1032Medicare PIN