Provider Demographics
NPI:1699965335
Name:MOONEY EYECARE CENTRE, PLLC
Entity type:Organization
Organization Name:MOONEY EYECARE CENTRE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LUTES
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:502-538-4632
Mailing Address - Street 1:327 EASTBROOKE DR # 100
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-5561
Mailing Address - Country:US
Mailing Address - Phone:502-538-4362
Mailing Address - Fax:502-538-3551
Practice Address - Street 1:327 EASTBROOKE DR # 100
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-5561
Practice Address - Country:US
Practice Address - Phone:502-538-4362
Practice Address - Fax:502-538-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1714DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100026420Medicaid
KY5991520001Medicare NSC
KY00448Medicare PIN
KY7100026420Medicaid