MEDICARE: PREMIER EYE CARE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TA 2181	MD

General Provider Information

NPI Number	:	1518224922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER EYE CARE CENTER LLC

Provider Business Mailing Address
First Line	:	12164 CENTRAL AVE STE 220
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-1903
Country	:	US
Telephone Number	:	301-218-1862
Fax Number	:	301-218-1864

Provider Business Practice Location Address
First Line	:	12164 CENTRAL AVE STE 220
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-1903
Country	:	US
Telephone Number	:	301-218-1862
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ESEOSA OMORUYI
Credential	:
Telephone Number	:	301-218-1862

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	04/16/2021

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Directions to “PREMIER EYE CARE CENTER LLC ” Practice Location

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