Provider Demographics
NPI:1053615286
Name:COMMUNITY VISION THERAPY ASSOCIATES
Entity type:Organization
Organization Name:COMMUNITY VISION THERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOWERSOX
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:502-647-3937
Mailing Address - Street 1:403 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1127
Mailing Address - Country:US
Mailing Address - Phone:502-647-3937
Mailing Address - Fax:
Practice Address - Street 1:403 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1127
Practice Address - Country:US
Practice Address - Phone:502-647-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1301DT152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013019Medicaid
KY0503210Medicare PIN
KYU46013Medicare UPIN