Provider Demographics
NPI:1174668693
Name:EYE RESTORATION CLINIC INC.
Entity Type:Organization
Organization Name:EYE RESTORATION CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEAKEM
Authorized Official - Suffix:
Authorized Official - Credentials:OCULARIST
Authorized Official - Phone:301-599-6300
Mailing Address - Street 1:9450 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE #15
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3665
Mailing Address - Country:US
Mailing Address - Phone:301-599-6300
Mailing Address - Fax:301-599-0578
Practice Address - Street 1:9450 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE #15
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3665
Practice Address - Country:US
Practice Address - Phone:301-599-6300
Practice Address - Fax:301-599-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3853156FX1700X
MD332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD30877OtherKAISER PERMANANTE
DC406540466OtherMEDICARE RR
DC023053600Medicaid
MD468228900Medicaid
DC023053600Medicaid
MD30877OtherKAISER PERMANANTE
MD468228900Medicaid