Provider Demographics
NPI:1467620708
Name:BROOKE PLAZA OPTICAL, INC.
Entity Type:Organization
Organization Name:BROOKE PLAZA OPTICAL, INC.
Other - Org Name:PLAZA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-678-1616
Mailing Address - Street 1:3450 LONG BEACH RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5440
Mailing Address - Country:US
Mailing Address - Phone:516-678-1616
Mailing Address - Fax:516-764-2711
Practice Address - Street 1:3450 LONG BEACH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5440
Practice Address - Country:US
Practice Address - Phone:516-678-1616
Practice Address - Fax:516-764-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT2830-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100001178Medicare PIN
0603660001Medicare NSC