# MR. JIMMIE TANTILLO PHELPS

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1740440742
- **Gender:** Man
- **Credential:** PSC

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 156FX1800X | Optician | 325 | KY | Yes |

## Other

- **Enumeration date:** 06/12/2008
- **Last updated:** 06/12/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 52800919 | — | KY |
| 01 | — | OP0933 | EYE MED | KY |