Provider Demographics
NPI:1356736789
Name:MLBOD, LLC
Entity type:Organization
Organization Name:MLBOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOMSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-456-1001
Mailing Address - Street 1:727 FREDERICK RD
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4503
Mailing Address - Country:US
Mailing Address - Phone:410-744-1111
Mailing Address - Fax:410-744-1200
Practice Address - Street 1:727 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4503
Practice Address - Country:US
Practice Address - Phone:410-744-1111
Practice Address - Fax:410-744-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD910LMedicare PIN