Provider Demographics
NPI:1285667469
Name:BROOKNEAL OPTICAL, INC
Entity Type:Organization
Organization Name:BROOKNEAL OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/REGISTERED OPTICAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:RO
Authorized Official - Phone:434-821-0268
Mailing Address - Street 1:207 E. RUSH STREET
Mailing Address - Street 2:P.O. BOX 100
Mailing Address - City:BROOKNEAL
Mailing Address - State:VA
Mailing Address - Zip Code:24528-0100
Mailing Address - Country:US
Mailing Address - Phone:434-376-3937
Mailing Address - Fax:434-376-3937
Practice Address - Street 1:207 E. RUSH STREET
Practice Address - Street 2:
Practice Address - City:BROOKNEAL
Practice Address - State:VA
Practice Address - Zip Code:24528-0100
Practice Address - Country:US
Practice Address - Phone:434-376-3937
Practice Address - Fax:434-376-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101002145156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3941060001Medicare ID - Type Unspecified