Provider Demographics
NPI:1902843378
Name:CENTRAL KENTUCKY OPTOMETRIC ASSOCIATES PSC
Entity Type:Organization
Organization Name:CENTRAL KENTUCKY OPTOMETRIC ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECTREAS
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLLINGSWORTH-CECCONI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-692-1871
Mailing Address - Street 1:310 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1428
Mailing Address - Country:US
Mailing Address - Phone:270-692-1871
Mailing Address - Fax:270-692-6785
Practice Address - Street 1:310 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1428
Practice Address - Country:US
Practice Address - Phone:270-692-1871
Practice Address - Fax:270-692-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2009-01-26
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
KY1902843378OtherRAILROAD MEDICARE
KY77903391Medicaid
KY77903391Medicaid
KY1278880002Medicare NSC