Individual
MR. JIMMIE TANTILLO PHELPS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSC
Contact information
Practice address
205 GERI LN, RICHMOND, KY 40475-2359
(859) 623-4267
(859) 623-4249
Mailing address
205 GERI LN, RICHMOND, KY 40475-2359
(859) 623-4267
(859) 623-4249
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
325
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
52800919
—
KY
01
—
OP0933
EYE MED
KY
Enumeration date
06/12/2008
Last updated
06/12/2008
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