Provider Demographics
NPI:1912221144
Name:NIALE SIRI OPTICAL CARE LLC
Entity Type:Organization
Organization Name:NIALE SIRI OPTICAL CARE LLC
Other - Org Name:NIALE SIRI OPTICAL CARE LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-475-7778
Mailing Address - Street 1:3806 ROKEBY RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1935
Mailing Address - Country:US
Mailing Address - Phone:443-475-7778
Mailing Address - Fax:443-873-8281
Practice Address - Street 1:3806 ROKEBY RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1935
Practice Address - Country:US
Practice Address - Phone:443-475-7778
Practice Address - Fax:443-873-8281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03326903156FX1201X
MD03374910156FX1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric TechnicianGroup - Single Specialty
No156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419335100Medicaid