Healthcare Provider Details

I. General information

NPI: 1861529240
Provider Name (Legal Business Name): LONGMEADOW OPTICAL, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 HAYWARD RD STE 202
FREDERICK MD
21702-2509
US

IV. Provider business mailing address

7420 HAYWARD RD STE 202
FREDERICK MD
21702-2509
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-8866
  • Fax: 301-293-6133
Mailing address:
  • Phone: 301-662-8866
  • Fax: 301-293-6133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number10199942
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1338
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA0646
License Number StateMD

VIII. Authorized Official

Name: DAWN R. GILL
Title or Position: OWNER
Credential: O.D.
Phone: 301-662-8866