Provider Demographics
NPI:1447402193
Name:MOBILE OPTICAL SERVICE, LLC
Entity type:Organization
Organization Name:MOBILE OPTICAL SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:410-664-4508
Mailing Address - Street 1:4200 ELDERON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4802
Mailing Address - Country:US
Mailing Address - Phone:410-664-4508
Mailing Address - Fax:410-664-0605
Practice Address - Street 1:4200 ELDERON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4802
Practice Address - Country:US
Practice Address - Phone:410-664-4508
Practice Address - Fax:410-664-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD072195332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier