Provider Demographics
NPI:1558485839
Name:FAMILY EYEHEALTH CENTER, LLC
Entity Type:Organization
Organization Name:FAMILY EYEHEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:PENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:859-363-3347
Mailing Address - Street 1:1824 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-8196
Mailing Address - Country:US
Mailing Address - Phone:859-363-3347
Mailing Address - Fax:
Practice Address - Street 1:1824 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-8196
Practice Address - Country:US
Practice Address - Phone:859-363-3347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1168DT152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903938Medicaid
KY9661Medicare ID - Type Unspecified
KY77903938Medicaid