Provider Demographics
NPI:1639203474
Name:PROFESSIONAL EYECARE, P.S.C.
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE, P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-789-4675
Mailing Address - Street 1:341 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1051
Mailing Address - Country:US
Mailing Address - Phone:606-789-4675
Mailing Address - Fax:606-789-3262
Practice Address - Street 1:341 COURT ST
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1051
Practice Address - Country:US
Practice Address - Phone:606-789-4675
Practice Address - Fax:606-789-3262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77900660Medicaid
KY0842338OtherUMWA HEALTH & RETIREMENT
KY77900660Medicaid
KY3927750001Medicare NSC
KY8823Medicare PIN
KY0842338OtherUMWA HEALTH & RETIREMENT