Provider Demographics
NPI:1427299916
Name:ED OPTICAL LLC
Entity type:Organization
Organization Name:ED OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AYODELE
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAYISI
Authorized Official - Suffix:
Authorized Official - Credentials:DISPENSING OPTICIAN
Authorized Official - Phone:301-885-0016
Mailing Address - Street 1:3370 LEONARDTOWN RD
Mailing Address - Street 2:SUITE 232
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3624
Mailing Address - Country:US
Mailing Address - Phone:301-885-0016
Mailing Address - Fax:206-600-4463
Practice Address - Street 1:3370 LEONARDTOWN RD
Practice Address - Street 2:SUITE 232
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3624
Practice Address - Country:US
Practice Address - Phone:301-885-0016
Practice Address - Fax:206-600-4463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization