Provider Demographics
NPI:1114206943
Name:POOLESVILLE VISION AND CONTACT LENS SERVICE
Entity Type:Organization
Organization Name:POOLESVILLE VISION AND CONTACT LENS SERVICE
Other - Org Name:POOLESVILLE VISION SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEVISSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-916-3214
Mailing Address - Street 1:20005 B FISHER AVE
Mailing Address - Street 2:
Mailing Address - City:POOLESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20837-2408
Mailing Address - Country:US
Mailing Address - Phone:301-916-3214
Mailing Address - Fax:301-916-3101
Practice Address - Street 1:20005 B FISHER AVE
Practice Address - Street 2:
Practice Address - City:POOLESVILLE
Practice Address - State:MD
Practice Address - Zip Code:20837-2408
Practice Address - Country:US
Practice Address - Phone:301-916-3214
Practice Address - Fax:301-916-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1222152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD212344Medicare PIN