Healthcare Provider Details

I. General information

NPI: 1356435572
Provider Name (Legal Business Name): SELECT EYE CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 LASALLE RD 108
TOWSON MD
21286-2005
US

IV. Provider business mailing address

8601 LASALLE RD 108
TOWSON MD
21286-2005
US

V. Phone/Fax

Practice location:
  • Phone: 410-821-6400
  • Fax: 410-339-3846
Mailing address:
  • Phone: 410-821-6400
  • Fax: 410-339-3846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1383
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0050028
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0006791
License Number StateMD

VIII. Authorized Official

Name: DR. SCOTT E LABORWIT
Title or Position: SECRETARY
Credential: MD
Phone: 410-821-6400