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General NPI Number Information
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NPI Number | 1790923605
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Entity Type | Organization
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Legal Business Name | PROVIDENCE OPTICIANS DESIGNER EYEWEAR INC
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Dates
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Enumeration Date | 01/30/2009
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Last Update Date | 01/24/2013
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Provider Practice Location Address
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Address Line | 3510 12TH ST NE
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City | WASHINGTON
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State | DC
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Zip | 20017-2544
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Country | US
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Telephone | 202-526-0300
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Fax | 202-526-0233
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Provider Business Mailing Address
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Address Line | 3510 12TH ST NE
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City | WASHINGTON
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State | DC
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Zip | 20017-2544
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Country | US
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Telephone | 202-526-0300
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Fax | 202-526-0233
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Authorized Official
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Title or Position | PRESIDENT
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Name | KYLE E. WINSLOW
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Credential | OPTICIAN
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Telephone | 202-462-0055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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