Provider Demographics
NPI:1831314806
Name:DESIGNER EYEWEAR INC
Entity Type:Organization
Organization Name:DESIGNER EYEWEAR INC
Other - Org Name:ST. MATTHEWS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-896-4497
Mailing Address - Street 1:4159 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3202
Mailing Address - Country:US
Mailing Address - Phone:502-896-4497
Mailing Address - Fax:502-896-1624
Practice Address - Street 1:4159 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3202
Practice Address - Country:US
Practice Address - Phone:502-896-4497
Practice Address - Fax:502-896-1624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 965156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0693490001Medicare NSC