Healthcare Provider Details

I. General information

NPI: 1114206943
Provider Name (Legal Business Name): POOLESVILLE VISION AND CONTACT LENS SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20005 B FISHER AVE
POOLESVILLE MD
20837-2408
US

IV. Provider business mailing address

20005 B FISHER AVE
POOLESVILLE MD
20837-2408
US

V. Phone/Fax

Practice location:
  • Phone: 301-916-3214
  • Fax: 301-916-3101
Mailing address:
  • Phone: 301-916-3214
  • Fax: 301-916-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTA1222
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberTA1222
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTA1222
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberTA1222
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTA1222
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberTA1222
License Number StateMD
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1222
License Number StateMD

VIII. Authorized Official

Name: MRS. ROBIN MEVISSEN
Title or Position: OWNER
Credential: O.D.
Phone: 310-916-3214