Provider Demographics
NPI:1669661690
Name:MOUNTAIN OPTICAL, LLC
Entity Type:Organization
Organization Name:MOUNTAIN OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KECK
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:606-248-6030
Mailing Address - Street 1:2145 US HIGHWAY 25 E
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1874
Mailing Address - Country:US
Mailing Address - Phone:606-248-6030
Mailing Address - Fax:606-248-0014
Practice Address - Street 1:2145 US HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1874
Practice Address - Country:US
Practice Address - Phone:606-248-6030
Practice Address - Fax:606-248-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1800X
KY0478332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000072724OtherBCBS
KY52904786Medicaid
KYKY0478OtherEYEMED
KY000000072724OtherBCBS