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General NPI Number Information
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NPI Number | 1720292865
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Entity Type | Organization
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Legal Business Name | CUSTOM EYES OPTICAL
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11977 REISTERSTOWN RD
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City | REISTERSTOWN
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State | MD
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Zip | 21136-3030
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Country | US
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Telephone | 410-833-1910
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Fax | 410-833-1911
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Provider Business Mailing Address
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Address Line | 11977 REISTERSTOWN RD
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City | REISTERSTOWN
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State | MD
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Zip | 21136-3030
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Country | US
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Telephone | 410-833-1910
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Fax | 410-833-1911
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Authorized Official
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Title or Position | PRES
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Name | MR. FRED HAVELOCK
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Credential | OPTN
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Telephone | 410-833-1910
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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 | TA0666
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License Number State | MD
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