Provider Demographics
NPI:1922537067
Name:EYEROSIE LLC
Entity Type:Organization
Organization Name:EYEROSIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIDDIQUI
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-741-8920
Mailing Address - Street 1:4500 FORBES BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-6316
Mailing Address - Country:US
Mailing Address - Phone:443-741-8920
Mailing Address - Fax:443-203-2617
Practice Address - Street 1:4500 FORBES BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6316
Practice Address - Country:US
Practice Address - Phone:443-741-8920
Practice Address - Fax:443-203-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205786261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR205786OtherSTATE LICENSE