Provider Demographics
NPI:1972017358
Name:CHIPPEWA OPTICAL LLC
Entity type:Organization
Organization Name:CHIPPEWA OPTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOVID
Authorized Official - Middle Name:PINCHUS
Authorized Official - Last Name:BERKOVITS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-406-7951
Mailing Address - Street 1:305 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-5313
Mailing Address - Country:US
Mailing Address - Phone:410-406-7951
Mailing Address - Fax:443-648-9001
Practice Address - Street 1:305 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-5313
Practice Address - Country:US
Practice Address - Phone:410-406-7951
Practice Address - Fax:443-648-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD555350400Medicaid