Provider Demographics
NPI:1437375714
Name:SHOUSE OPTICAL SERVICE, INCORPORATED
Entity Type:Organization
Organization Name:SHOUSE OPTICAL SERVICE, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILL
Authorized Official - Last Name:SHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:859-276-1594
Mailing Address - Street 1:101 MALABU DR
Mailing Address - Street 2:SUITE #7
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3141
Mailing Address - Country:US
Mailing Address - Phone:859-276-1594
Mailing Address - Fax:859-277-6421
Practice Address - Street 1:101 MALABU DR
Practice Address - Street 2:SUITE #7
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3141
Practice Address - Country:US
Practice Address - Phone:859-276-1594
Practice Address - Fax:859-277-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000073323OtherANTHEM BCBS
KY52902384Medicaid
KY52902384Medicaid