Healthcare Provider Details

I. General information

NPI: 1174668693
Provider Name (Legal Business Name): EYE RESTORATION CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

9450 PENNSYLVANIA AVE SUITE #15
UPPER MARLBORO MD
20772-3665
US

IV. Provider business mailing address

9450 PENNSYLVANIA AVE SUITE #15
UPPER MARLBORO MD
20772-3665
US

V. Phone/Fax

Practice location:
  • Phone: 301-599-6300
  • Fax: 301-599-0578
Mailing address:
  • Phone: 301-599-6300
  • Fax: 301-599-0578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number3853
License Number StateMD

VIII. Authorized Official

Name: MR. THOMAS MEAKEM
Title or Position: OWNER
Credential: OCULARIST
Phone: 301-599-6300