Provider Demographics
NPI:1205941135
Name:DR. J PSC
Entity type:Organization
Organization Name:DR. J PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-340-9541
Mailing Address - Street 1:611 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-1761
Mailing Address - Country:US
Mailing Address - Phone:606-340-9541
Mailing Address - Fax:606-677-6542
Practice Address - Street 1:1461 E HIGHWAY 90 BYP
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2327
Practice Address - Country:US
Practice Address - Phone:606-340-9541
Practice Address - Fax:606-677-6542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1552DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903680Medicaid
KYU91611Medicare UPIN
KY77903680Medicaid