Organization
BLUEGRASS EYECARE CENTER, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. W DOUGLAS BACK M.D. (SECRETARY/MEMBER)
(859) 278-8443
Entity
Organization
Contact information
Practice address
715 SHAKER DR, SUITE 120, LEXINGTON, KY 40504-3674
(859) 278-8443
Mailing address
715 SHAKER DR, SUITE 120, LEXINGTON, KY 40504-3674
(859) 278-8443
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
207W00000X
Ophthalmology Physician
Primary
21381
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00599
MEDICARE GROUP NUMBER
—
05
—
7100030920
—
KY
Enumeration date
02/20/2008
Last updated
09/08/2008
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