Provider Demographics
NPI:1376729798
Name:TERESA L MADDEN, PSC
Entity Type:Organization
Organization Name:TERESA L MADDEN, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-598-2219
Mailing Address - Street 1:231 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-1214
Mailing Address - Country:US
Mailing Address - Phone:606-598-2219
Mailing Address - Fax:606-598-7972
Practice Address - Street 1:231 WHITE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-1214
Practice Address - Country:US
Practice Address - Phone:606-598-2219
Practice Address - Fax:606-598-7972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0955DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9688Medicare PIN
KY4931900001Medicare NSC