Basic Information
Provider Information | |||||||||
NPI: | 1396927935 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | J. KENDALL CECIL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EAST KENTUCKY EYECARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3469 N MAYO TRL | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415013265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064325800 | ||||||||
FaxNumber: | 6064372307 | ||||||||
Practice Location | |||||||||
Address1: | 3469 N MAYO TRL | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415013265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064325800 | ||||||||
FaxNumber: | 6064321728 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2007 | ||||||||
LastUpdateDate: | 08/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEWSOME | ||||||||
AuthorizedOfficialFirstName: | DIANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6064325800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1043DT | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.