Provider Demographics
NPI:1598838385
Name:BLUEGRASS FAMILY EYECARE INC.
Entity Type:Organization
Organization Name:BLUEGRASS FAMILY EYECARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHREWSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-274-3294
Mailing Address - Street 1:1303 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320
Practice Address - Country:US
Practice Address - Phone:270-274-3294
Practice Address - Fax:270-274-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0956DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903607Medicaid
KY7580Medicare PIN