Provider Demographics
NPI:1609071679
Name:SOUTH EAST EYECARE PSC
Entity Type:Organization
Organization Name:SOUTH EAST EYECARE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:606-528-7336
Mailing Address - Street 1:1707 FALLS ROAD PLAZA
Mailing Address - Street 2:SUITE U-4
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701
Mailing Address - Country:US
Mailing Address - Phone:606-528-7336
Mailing Address - Fax:606-523-9189
Practice Address - Street 1:1707 FALLS ROAD PLAZA
Practice Address - Street 2:SUITE U-4
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-528-7336
Practice Address - Fax:606-523-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165742156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty