Provider Demographics
NPI:1982121570
Name:MAVERICK OPTICAL LLC
Entity Type:Organization
Organization Name:MAVERICK OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASST
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:606-564-8794
Mailing Address - Street 1:1937 OLD MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8956
Mailing Address - Country:US
Mailing Address - Phone:606-759-7311
Mailing Address - Fax:606-759-0610
Practice Address - Street 1:1937 OLD MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8956
Practice Address - Country:US
Practice Address - Phone:606-759-7311
Practice Address - Fax:606-759-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110718156FX1800X, 332H00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093159626OtherNPI
KY7100246390Medicaid
1427041037OtherNPI
KY52000155Medicaid