Healthcare Provider Details

I. General information

NPI: 1013603380
Provider Name (Legal Business Name): MAISHA OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 E MCANDREWS RD STE 100
MEDFORD OR
97504-6497
US

IV. Provider business mailing address

1251 E MCANDREWS RD STE 100
MEDFORD OR
97504-6497
US

V. Phone/Fax

Practice location:
  • Phone: 808-264-4810
  • Fax:
Mailing address:
  • Phone: 808-264-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MAISHA LANGELLA
Title or Position: OWNER
Credential:
Phone: 808-677-7727