Provider Demographics
NPI:1851443394
Name:SOUTHEASTERN EYE CARE CLINIC
Entity Type:Organization
Organization Name:SOUTHEASTERN EYE CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JO
Authorized Official - Last Name:HOLBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-672-2040
Mailing Address - Street 1:21937 MAIN STREET
Mailing Address - Street 2:PO DRW 778
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-0778
Mailing Address - Country:US
Mailing Address - Phone:606-672-2040
Mailing Address - Fax:606-672-3937
Practice Address - Street 1:21937 MAIN ST.
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749
Practice Address - Country:US
Practice Address - Phone:606-672-2040
Practice Address - Fax:606-672-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0902DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009025Medicaid
KY0290480001Medicare NSC
KYT54708Medicare UPIN
KY8415Medicare PIN