Provider Demographics
NPI:1679745756
Name:KENTUCKY OPTICAL EXPRESS, INC.
Entity Type:Organization
Organization Name:KENTUCKY OPTICAL EXPRESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:BULLARD
Authorized Official - Last Name:GUERRANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:888-497-2117
Mailing Address - Street 1:122 STONE TRACE DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-5242
Mailing Address - Country:US
Mailing Address - Phone:888-497-2117
Mailing Address - Fax:859-497-2542
Practice Address - Street 1:122 STONE TRACE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353
Practice Address - Country:US
Practice Address - Phone:888-497-2117
Practice Address - Fax:859-497-2542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6177100001Medicare NSC