Provider Demographics
NPI:1821089640
Name:OAK TREE EYE CLINIC INC PSC
Entity Type:Organization
Organization Name:OAK TREE EYE CLINIC INC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDDIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-754-4515
Mailing Address - Street 1:1601 WEST EVERLY BROTHERS BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330-0676
Mailing Address - Country:US
Mailing Address - Phone:270-754-4515
Mailing Address - Fax:270-754-2547
Practice Address - Street 1:1601 WEST EVERLY BROTHERS BLVD
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330-0676
Practice Address - Country:US
Practice Address - Phone:270-754-4515
Practice Address - Fax:270-754-2547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903906Medicaid
KY5048640001Medicare NSC
9090Medicare PIN
KYDB4678Medicare PIN