Provider Demographics
NPI:1275617276
Name:TRI-STATE DOCTORS OF
Entity Type:Organization
Organization Name:TRI-STATE DOCTORS OF
Other - Org Name:KY DOCTORS OF OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBESH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-750-8384
Mailing Address - Street 1:PO BOX 846027
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6027
Mailing Address - Country:US
Mailing Address - Phone:726-444-4069
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:4655 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3970
Practice Address - Country:US
Practice Address - Phone:502-966-2020
Practice Address - Fax:502-966-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7790293000Medicaid
KY7790293000Medicaid