1104848050 NPI number — FS OPTOMETRY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104848050 NPI number — FS OPTOMETRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FS OPTOMETRY LLC
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:
ASHBURN VISION SOURCE
Provider Other Organization Name Type Code:
3
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:
1104848050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44075 PIPELINE PLZ
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20147-5881
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-724-9948
Provider Business Mailing Address Fax Number:
703-724-9949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44075 PIPELINE PLZ
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ASHBURN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20147-5881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-724-9948
Provider Business Practice Location Address Fax Number:
703-724-9949
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HINKLE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MANAGING OPTOMETRIST
Authorized Official Telephone Number:
703-724-9948

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618001162 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0618001162 . This is a "STATE LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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