Provider Demographics
NPI:1881877785
Name:MACKEY VISION CENTER PSC
Entity type:Organization
Organization Name:MACKEY VISION CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-528-1143
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:281 N. COMMONWEALTH AVE.
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40702
Practice Address - Country:US
Practice Address - Phone:606-528-1143
Practice Address - Fax:606-523-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
KY37261207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64052327Medicaid
KY77007128Medicaid
KY0778201Medicare PIN
KYT54628Medicare UPIN
KY77007128Medicaid
KYH65577Medicare UPIN
KY64052327Medicaid