Provider Demographics
NPI:1932801362
Name:ROUTE 33 EYE CARE & OPTICAL BOUTIQUE LLC
Entity Type:Organization
Organization Name:ROUTE 33 EYE CARE & OPTICAL BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-298-9913
Mailing Address - Street 1:510 TENANT CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAELS
Mailing Address - State:MD
Mailing Address - Zip Code:21663-2873
Mailing Address - Country:US
Mailing Address - Phone:954-298-9913
Mailing Address - Fax:
Practice Address - Street 1:1013 S TALBOT ST
Practice Address - Street 2:
Practice Address - City:SAINT MICHAELS
Practice Address - State:MD
Practice Address - Zip Code:21663-2637
Practice Address - Country:US
Practice Address - Phone:954-298-9913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty