Healthcare Provider Details

I. General information

NPI: 1730330010
Provider Name (Legal Business Name): EAGLE EYE VISION ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13830 OUTLET DR
SILVER SPRING MD
20904-4970
US

IV. Provider business mailing address

13830 OUTLET DR
SILVER SPRING MD
20904-4970
US

V. Phone/Fax

Practice location:
  • Phone: 301-890-9779
  • Fax: 301-890-0923
Mailing address:
  • Phone: 301-890-9779
  • Fax: 301-890-0923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1176
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SCOTT KLASMAN
Title or Position: MEMBER
Credential: O.D.
Phone: 301-890-9779