Provider Demographics
NPI:1619586617
Name:CHANDLER, ALICIA (LDO)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11605 BRAGG AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1353
Mailing Address - Country:US
Mailing Address - Phone:502-500-7252
Mailing Address - Fax:
Practice Address - Street 1:11605 BRAGG AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1353
Practice Address - Country:US
Practice Address - Phone:502-500-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-25
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY166435156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY166435OtherOPTICAN