Provider Demographics
NPI:1790897924
Name:EYECARE CENTER OF PRINCETON PLLC
Entity Type:Organization
Organization Name:EYECARE CENTER OF PRINCETON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-365-6627
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445-0683
Mailing Address - Country:US
Mailing Address - Phone:270-365-6627
Mailing Address - Fax:270-365-7700
Practice Address - Street 1:101 E SHEPARDSON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-1633
Practice Address - Country:US
Practice Address - Phone:270-365-6627
Practice Address - Fax:270-365-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY933 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100384690Medicaid
KY933 DTOtherKY LICENSE NUMBER
KY7100384690Medicaid
KY7481490001Medicare NSC
KYT54663Medicare UPIN
KY3830Medicare PIN