=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588735609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T&L OPTICAL SUPPLY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2006
-----------------------------------------------------
Last Update Date | 04/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 GEORGETOWN BLVD SUITE 121
-----------------------------------------------------
City | ELDERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-6481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-795-8670
-----------------------------------------------------
Fax | 410-795-2680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 GEORGETOWN BLVD SUITE 121
-----------------------------------------------------
City | ELDERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-6481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-795-8670
-----------------------------------------------------
Fax | 410-795-2680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. MICHAEL I. DAVIS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 410-795-8670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------