Provider Demographics
NPI:1720600893
Name:BEALL, BROOKE TAYLOR (OD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:TAYLOR
Last Name:BEALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 FALLBROOK BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-9025
Mailing Address - Country:US
Mailing Address - Phone:402-742-0399
Mailing Address - Fax:027-420-4954
Practice Address - Street 1:570 FALLBROOK BLVD STE 108
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-9025
Practice Address - Country:US
Practice Address - Phone:402-742-0399
Practice Address - Fax:027-420-4954
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1512152W00000X
NE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE41600Medicaid