Provider Demographics
NPI:1659998524
Name:PCD MANAGEMENT OF PADUCAH, LLC
Entity Type:Organization
Organization Name:PCD MANAGEMENT OF PADUCAH, LLC
Other - Org Name:PCD MANAGEMENT OF PADUCAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVYDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-800-2020
Mailing Address - Street 1:5312 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-6110
Mailing Address - Country:US
Mailing Address - Phone:918-895-1700
Mailing Address - Fax:
Practice Address - Street 1:467 JORDAN DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001
Practice Address - Country:US
Practice Address - Phone:270-297-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty