MEDICARE: CUSTOM EYES OPTICAL

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	TA0666	MD

General Provider Information

NPI Number	:	1720292865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM EYES OPTICAL

Provider Business Mailing Address
First Line	:	11977 REISTERSTOWN RD
Second Line	:
City	:	REISTERSTOWN
State	:	MD
Zip	:	21136-3030
Country	:	US
Telephone Number	:	410-833-1910
Fax Number	:	410-833-1911

Provider Business Practice Location Address
First Line	:	11977 REISTERSTOWN RD
Second Line	:
City	:	REISTERSTOWN
State	:	MD
Zip	:	21136-3030
Country	:	US
Telephone Number	:	410-833-1910
Fax Number	:	410-833-1911

Authorized Official
Title or Position	:	PRES
Name	:	MR. FRED HAVELOCK
Credential	:	OPTN
Telephone Number	:	410-833-1910

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	08/22/2020

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