Provider Demographics
NPI:1871829945
Name:CROCKETT FAMILY VISION CENTER
Entity Type:Organization
Organization Name:CROCKETT FAMILY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-498-4800
Mailing Address - Street 1:25 STERLING WAY STE C
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 STERLING WAY STE C
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1174
Practice Address - Country:US
Practice Address - Phone:859-498-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1342DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000062161OtherANTHEM
KY77013423Medicaid
KY1163000001Medicare NSC
KYU64529Medicare UPIN
KY1640701Medicare Oscar/Certification