Healthcare Provider Details

I. General information

NPI: 1144468059
Provider Name (Legal Business Name): PROVIDENCE OPTICIANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 11TH ST NW
WASHINGTON DC
20001-5021
US

IV. Provider business mailing address

1802 11TH ST NW
WASHINGTON DC
20001-5021
US

V. Phone/Fax

Practice location:
  • Phone: 202-462-0055
  • Fax: 202-462-2837
Mailing address:
  • Phone: 202-462-0055
  • Fax: 202-462-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD M WINSLOW
Title or Position: OWNER/ PRESIDENT
Credential:
Phone: 202-462-0055