Basic Information
| Provider Information | |||||||||
| NPI: | 1366698326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LENSTEK LTD. T/A PEARLE VISION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LENSTEK LTD. T/A PEARLE VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 278 | ||||||||
| Address2: | 14455 OAKS ROAD | ||||||||
| City: | CHARLOTTE HALL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206220278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018842391 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3005 LEONARDTOWN RD | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206013136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016456550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | EVALENA | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2402980099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OPTICIAN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | MD | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.