Healthcare Provider Details

I. General information

NPI: 1760918924
Provider Name (Legal Business Name): SAINT LUKES OPTICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N POINT BLVD SUITE 704
BALTIMORE MD
21224
US

IV. Provider business mailing address

11909 MINOR JONES DRIVE
OWINGS MILLS MD
21117
US

V. Phone/Fax

Practice location:
  • Phone: 410-282-6767
  • Fax: 410-282-3777
Mailing address:
  • Phone: 410-277-3937
  • Fax: 410-281-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: IVAN GARCIA
Title or Position: OWNER
Credential: MD
Phone: 410-371-7905