Healthcare Provider Details

I. General information

NPI: 1275653495
Provider Name (Legal Business Name): TYSONS OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 TYSONS CORNER CTR
MCLEAN VA
22102-4505
US

IV. Provider business mailing address

1880 HOWARD AVE STE 301B
VIENNA VA
22182-2611
US

V. Phone/Fax

Practice location:
  • Phone: 703-734-0977
  • Fax: 703-893-7134
Mailing address:
  • Phone: 703-761-9504
  • Fax: 703-761-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number736368
License Number StateVA

VIII. Authorized Official

Name: MRS. ANA D PUHL
Title or Position: VICE PRESIDENT
Credential:
Phone: 703-734-0799