Provider Demographics
NPI:1508255464
Name:FOUR RIVERS VISION THERAPY, PLLC
Entity Type:Organization
Organization Name:FOUR RIVERS VISION THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CANAAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-558-4741
Mailing Address - Street 1:4570 PECAN DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6717
Mailing Address - Country:US
Mailing Address - Phone:270-558-4741
Mailing Address - Fax:270-558-4742
Practice Address - Street 1:4570 PECAN DR
Practice Address - Street 2:SUITE C
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6717
Practice Address - Country:US
Practice Address - Phone:270-558-4741
Practice Address - Fax:270-558-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1958DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty