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General NPI Number Information
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NPI Number | 1184744310
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Entity Type | Organization
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Legal Business Name | SPRINGFIELD MALL OPTICAL, INC.
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6795 SPRINGFIELD MALL
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City | SPRINGFIELD
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State | VA
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Zip | 22150-1704
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Country | US
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Telephone | 703-971-6026
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Fax | 703-971-8695
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Provider Business Mailing Address
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Address Line | 1880 HOWARD AVE STE 301B
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City | VIENNA
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State | VA
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Zip | 22182-2611
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Country | US
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Telephone | 703-761-9504
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Fax | 701-761-9542
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MRS. ANA D PUHL
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Credential |
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Telephone | 703-971-6026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 736363
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License Number State | VA
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