Healthcare Provider Details

I. General information

NPI: 1972017358
Provider Name (Legal Business Name): CHIPPEWA OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 REISTERSTOWN RD
BALTIMORE MD
21208-5313
US

IV. Provider business mailing address

305 REISTERSTOWN RD
PIKESVILLE MD
21208-5313
US

V. Phone/Fax

Practice location:
  • Phone: 410-406-7951
  • Fax: 443-648-9001
Mailing address:
  • Phone: 410-406-7951
  • Fax: 443-648-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: DOVID PINCHUS BERKOVITS
Title or Position: MEMBER
Credential:
Phone: 410-406-7951