=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225702400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAKE SCHERMER HOLDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2021
-----------------------------------------------------
Last Update Date | 08/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13010 MIDDLEBROOK RD
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20874-2617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-540-1555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13010 MIDDLEBROOK RD
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20874-2617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-540-1555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. BLAKE SCHERMER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 301-540-1555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------