Healthcare Provider Details

I. General information

NPI: 1639613755
Provider Name (Legal Business Name): CBKOPT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 TYSONS CORNER CTR
MC LEAN VA
22102-4525
US

IV. Provider business mailing address

902 CENTRILLION DR
MC LEAN VA
22102-1442
US

V. Phone/Fax

Practice location:
  • Phone: 703-447-2179
  • Fax:
Mailing address:
  • Phone: 703-447-2179
  • Fax: 703-848-8359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001234
License Number StateVA

VIII. Authorized Official

Name: DR. CHRISTINE E BAE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 703-447-2179