Provider Demographics
NPI:1154479657
Name:OPTICAL SHOP
Entity Type:Organization
Organization Name:OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-588-1177
Mailing Address - Street 1:8630 FENTON ST
Mailing Address - Street 2:SUITE 123
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3806
Mailing Address - Country:US
Mailing Address - Phone:301-589-7732
Mailing Address - Fax:301-589-5245
Practice Address - Street 1:8630 FENTON ST
Practice Address - Street 2:SUITE 123
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3806
Practice Address - Country:US
Practice Address - Phone:301-589-7732
Practice Address - Fax:301-589-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4336470001Medicare NSC