Provider Demographics
NPI:1548302839
Name:KENTUCKY INSTITUTE FOR EYE HEALTH & SURGERY
Entity type:Organization
Organization Name:KENTUCKY INSTITUTE FOR EYE HEALTH & SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMT,COE
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-278-9393
Mailing Address - Street 1:140L HARRODSBURG RD.
Mailing Address - Street 2:STE B 75
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-278-9393
Mailing Address - Fax:859-277-3965
Practice Address - Street 1:408 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1014
Practice Address - Country:US
Practice Address - Phone:606-743-4111
Practice Address - Fax:606-743-2018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1035DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77902500Medicaid
KY0968700003Medicare NSC
KY77902500Medicaid