Provider Demographics
NPI:1568536415
Name:OLE BROOK OPTICAL, INC
Entity Type:Organization
Organization Name:OLE BROOK OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED OPTICIAN
Authorized Official - Phone:601-833-3318
Mailing Address - Street 1:PO BOX 598
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601
Mailing Address - Country:US
Mailing Address - Phone:601-833-3318
Mailing Address - Fax:601-833-7782
Practice Address - Street 1:401 HWY 51 SOUTH
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601
Practice Address - Country:US
Practice Address - Phone:601-833-3318
Practice Address - Fax:601-833-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07256063Medicaid
MS5187120001Medicare NSC