Provider Demographics
NPI:1457514838
Name:SHOUSE OPTICAL SERVICE INC
Entity Type:Organization
Organization Name:SHOUSE OPTICAL SERVICE INC
Other - Org Name:JOHN W SHOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-276-1594
Mailing Address - Street 1:101 MALABU DR # 7
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3141
Mailing Address - Country:US
Mailing Address - Phone:859-276-1594
Mailing Address - Fax:859-277-6421
Practice Address - Street 1:101 MALABU DR # 7
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3141
Practice Address - Country:US
Practice Address - Phone:859-276-1594
Practice Address - Fax:859-277-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52902384Medicaid
KY52902384Medicaid