Provider Demographics
NPI:1497936256
Name:MCCLOUD EYE CARE CENTER INC
Entity Type:Organization
Organization Name:MCCLOUD EYE CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCLOUD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-474-5149
Mailing Address - Street 1:107 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1301
Mailing Address - Country:US
Mailing Address - Phone:606-474-5149
Mailing Address - Fax:606-474-0648
Practice Address - Street 1:107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1301
Practice Address - Country:US
Practice Address - Phone:606-474-5149
Practice Address - Fax:606-474-0648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1585DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7987OtherMEDICARE GROUP #
KY77903649Medicaid
KY77000859Medicaid
KYU96210Medicare UPIN
KY77000859Medicaid
KY77903649Medicaid