Provider Demographics
NPI:1427041037
Name:PECK, JOYCE C
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:C
Last Name:PECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAVERICK OPTICAL
Other - Middle Name:
Other - Last Name:OPTICAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41096-0054
Mailing Address - Country:US
Mailing Address - Phone:606-564-8794
Mailing Address - Fax:606-759-0610
Practice Address - Street 1:1937 OLD MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8956
Practice Address - Country:US
Practice Address - Phone:606-759-7311
Practice Address - Fax:606-759-0610
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111468156FX1800X, 156FX1800X, 332H00000X
KY0941332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1063563104OtherEMPLOYEE - IP
KY1093159626OtherNPI-ADAM BRADLEY
KY7100022560Medicaid
KY5200015500Medicaid
KY60537045OtherBLUE CROSS BLUE SHIELD
KY7100022560Medicaid
KY1093159626OtherNPI-ADAM BRADLEY