Provider Demographics
NPI:1124460621
Name:ADVANCED EYE CARE MEDICAL CENTER
Entity type:Organization
Organization Name:ADVANCED EYE CARE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOVELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-805-4664
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-805-4664
Mailing Address - Fax:
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:SUITE 116
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-805-4664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1790990505Medicare PIN