Healthcare Provider Details

I. General information

NPI: 1700945979
Provider Name (Legal Business Name): EDMONDS OPTICIAN OF SPRING VALLEY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MASSACHUSETTS AVE NW
WASHINGTON DC
20016-4358
US

IV. Provider business mailing address

4900 MASSACHUSETTS AVE NW
WASHINGTON DC
20016-4358
US

V. Phone/Fax

Practice location:
  • Phone: 202-237-0070
  • Fax: 202-237-9187
Mailing address:
  • Phone: 202-237-0070
  • Fax: 202-237-9187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL G. TATE
Title or Position: PRESIDENT
Credential:
Phone: 202-237-0070