Provider Demographics
NPI:1235493396
Name:CHESAPEAKE BAY OPTICAL LLC
Entity Type:Organization
Organization Name:CHESAPEAKE BAY OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-841-1909
Mailing Address - Street 1:2003 MEDICAL PKWY
Mailing Address - Street 2:SUITE G90
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7992
Mailing Address - Country:US
Mailing Address - Phone:410-841-1909
Mailing Address - Fax:410-571-8624
Practice Address - Street 1:2003 MEDICAL PKWY
Practice Address - Street 2:SUITE G90
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7992
Practice Address - Country:US
Practice Address - Phone:410-841-1909
Practice Address - Fax:410-571-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02526333332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier