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General NPI Number Information
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NPI Number | 1295263234
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Entity Type | Organization
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Legal Business Name | MAXIMEYES VISION SOURCE, LLC
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Dates
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Enumeration Date | 06/02/2017
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Last Update Date | 06/20/2017
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Provider Practice Location Address
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Address Line | 11011 LEE HWY
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City | FAIRFAX
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State | VA
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Zip | 22030-5002
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Country | US
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Telephone | 703-691-7584
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Fax | 703-591-6271
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Provider Business Mailing Address
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Address Line | 1390 CHAIN BRIDGE RD # 313
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City | MC LEAN
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State | VA
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Zip | 22101-3904
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Country | US
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Telephone | 703-691-7584
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | DR. MARIA PHAM
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Credential | OD
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Telephone | 703-691-7584
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618002092
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License Number State | VA
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