1073660452 NPI number — LOOKING GLASS OPTICAL CONTACTS AND EYEGLASSES

Table of content: (NPI 1073660452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073660452 NPI number — LOOKING GLASS OPTICAL CONTACTS AND EYEGLASSES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOOKING GLASS OPTICAL CONTACTS AND EYEGLASSES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073660452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8028 RITCHIE HWY
Provider Second Line Business Mailing Address:
SUITE 124
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21122-1075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-768-0202
Provider Business Mailing Address Fax Number:
410-768-1330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8028 RITCHIE HWY
Provider Second Line Business Practice Location Address:
SUITE 124
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21122-1075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-768-0202
Provider Business Practice Location Address Fax Number:
410-768-1330
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TELES
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
MARC
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
410-768-0202

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TA0974 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: T1680001 . This is a "CAREFIRST OF DC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: KEN4LO . This is a "CAREFIRST OF MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 603673 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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