Provider Demographics
NPI:1720292865
Name:CUSTOM EYES OPTICAL
Entity type:Organization
Organization Name:CUSTOM EYES OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVELOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OPTN
Authorized Official - Phone:410-833-1910
Mailing Address - Street 1:11977 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3030
Mailing Address - Country:US
Mailing Address - Phone:410-833-1910
Mailing Address - Fax:410-833-1911
Practice Address - Street 1:11977 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3030
Practice Address - Country:US
Practice Address - Phone:410-833-1910
Practice Address - Fax:410-833-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0666152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty