Provider Demographics
NPI:1477630754
Name:HENDERSON OPTICAL
Entity Type:Organization
Organization Name:HENDERSON OPTICAL
Other - Org Name:CITYVIEW OPTICAL
Other - Org Type:Doing Business As
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 1:5801 OAKBEND TRL
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3912
Mailing Address - Country:US
Mailing Address - Phone:817-263-4699
Mailing Address - Fax:817-263-9632
Practice Address - Street 1:5801 OAKBEND TRL
Practice Address - Street 2:STE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3912
Practice Address - Country:US
Practice Address - Phone:817-263-4699
Practice Address - Fax:817-263-9632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0556860001Medicare ID - Type Unspecified