Provider Demographics
NPI:1083791354
Name:HENDERSON OPTICAL, LLC
Entity Type:Organization
Organization Name:HENDERSON OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-336-3653
Mailing Address - Street 1:1201 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4413
Mailing Address - Country:US
Mailing Address - Phone:817-336-3653
Mailing Address - Fax:817-332-4233
Practice Address - Street 1:1201 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-4413
Practice Address - Country:US
Practice Address - Phone:817-336-3653
Practice Address - Fax:817-332-4233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019770901Medicaid