Provider Demographics
NPI:1750369120
Name:LEISURE WORLD OPTICIANS INC
Entity type:Organization
Organization Name:LEISURE WORLD OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:LICENCED OPTICIAN
Authorized Official - Phone:301-598-4614
Mailing Address - Street 1:3804 INTERNATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-1548
Mailing Address - Country:US
Mailing Address - Phone:301-598-4614
Mailing Address - Fax:301-598-4615
Practice Address - Street 1:3804 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-1548
Practice Address - Country:US
Practice Address - Phone:301-598-4614
Practice Address - Fax:301-598-4615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5656520001Medicare NSC
MDG02308Medicare PIN