Provider Demographics
NPI:1497089627
Name:JARRETTSVILLE FAMILY EYECARE LLC
Entity Type:Organization
Organization Name:JARRETTSVILLE FAMILY EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROLD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WASSEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-557-8800
Mailing Address - Street 1:3718 NORRISVILLE RD
Mailing Address - Street 2:STE. A
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-1419
Mailing Address - Country:US
Mailing Address - Phone:410-557-8800
Mailing Address - Fax:410-557-2811
Practice Address - Street 1:3718 NORRISVILLE RD
Practice Address - Street 2:STE. A
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21084-1419
Practice Address - Country:US
Practice Address - Phone:410-557-8800
Practice Address - Fax:410-557-2811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0769332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0314830001Medicare NSC