Provider Demographics
NPI:1275712416
Name:EDMONTON FAMILY VISION CENTER PSC
Entity Type:Organization
Organization Name:EDMONTON FAMILY VISION CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:WHITLOW
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:270-432-0123
Mailing Address - Street 1:1406 W STOCKTON ST
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:KY
Mailing Address - Zip Code:42129-8125
Mailing Address - Country:US
Mailing Address - Phone:270-432-0123
Mailing Address - Fax:270-432-5899
Practice Address - Street 1:1406 W STOCKTON ST
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129-8125
Practice Address - Country:US
Practice Address - Phone:270-432-0123
Practice Address - Fax:270-432-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1226DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903250Medicaid
KY0411790001Medicare NSC
KY5877Medicare PIN