MEDICARE: MCNELLY OPTICAL COMPNAY INC.

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	332H00000X	Eyewear Supplier	02210330	MD

General Provider Information

NPI Number	:	1912188319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCNELLY OPTICAL COMPNAY INC.

Provider Business Mailing Address
First Line	:	703 GIDDINGS AVE
Second Line	:	SUITE L6
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-1411
Country	:	US
Telephone Number	:	410-263-2571
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 GIDDINGS AVE
Second Line	:	SUITE L6
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-1411
Country	:	US
Telephone Number	:	410-263-2571
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOHN ALBERT MARSHALL JR.
Credential	:
Telephone Number	:	410-263-2571

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	11/14/2007

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