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General NPI Number Information
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NPI Number | 1396766390
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Entity Type | Organization
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Legal Business Name | AN OPTICAL GALLERIA, LLC
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Dates
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Enumeration Date | 07/22/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 111 W WATER ST
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City | CENTREVILLE
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State | MD
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Zip | 21617-1030
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Country | US
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Telephone | 443-262-9415
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Fax | 443-262-9417
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Provider Business Mailing Address
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Address Line | 111 W WATER ST
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City | CENTREVILLE
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State | MD
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Zip | 21617-1030
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Country | US
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Telephone | 443-262-9415
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Fax | 443-262-9417
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT PINO
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Credential |
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Telephone | 443-262-9415
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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 | 17231525
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License Number State | MD
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