Provider Demographics
NPI:1619163169
Name:EYECARE CENTER OPTOMETRIST PSC
Entity Type:Organization
Organization Name:EYECARE CENTER OPTOMETRIST PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:859-623-3358
Mailing Address - Street 1:1020 GIBSON BAY DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3448
Mailing Address - Country:US
Mailing Address - Phone:859-623-3358
Mailing Address - Fax:859-623-3358
Practice Address - Street 1:201 CHAMPION WAY
Practice Address - Street 2:STE 1
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8828
Practice Address - Country:US
Practice Address - Phone:502-863-2020
Practice Address - Fax:502-867-4938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE CARE CENTER OPTOMETRIST PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-19
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1069DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9580Medicare PIN
KY1157440007Medicare NSC