Provider Demographics
NPI:1831146695
Name:LOGAN COUNTY EYE ASSOCIATES
Entity Type:Organization
Organization Name:LOGAN COUNTY EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASS
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESCARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-726-2022
Mailing Address - Street 1:105 ROBINS WAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1820
Mailing Address - Country:US
Mailing Address - Phone:270-726-2022
Mailing Address - Fax:270-726-2035
Practice Address - Street 1:105 ROBINS WAY
Practice Address - Street 2:SUITE 206
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1820
Practice Address - Country:US
Practice Address - Phone:270-726-2022
Practice Address - Fax:270-726-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77902435Medicaid
KY8843Medicare PIN
KYU68237Medicare UPIN