Provider Demographics
NPI:1295008803
Name:ELITE VISION CENTER LLC
Entity Type:Organization
Organization Name:ELITE VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-248-2549
Mailing Address - Street 1:1403 CUMBERLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1158
Mailing Address - Country:US
Mailing Address - Phone:606-248-2549
Mailing Address - Fax:606-248-9188
Practice Address - Street 1:1403 CUMBERLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1158
Practice Address - Country:US
Practice Address - Phone:606-248-2549
Practice Address - Fax:606-248-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 1711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100202310Medicaid
TN1526915Medicaid
TN1526915Medicaid
KYK036570Medicare PIN