Provider Demographics
NPI:1821080250
Name:BROOKHAVEN OPTICAL INC
Entity Type:Organization
Organization Name:BROOKHAVEN OPTICAL INC
Other - Org Name:OPTICAL OUTLET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATLIE
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:HERNDON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PHD
Authorized Official - Phone:601-833-1958
Mailing Address - Street 1:347 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3219
Mailing Address - Country:US
Mailing Address - Phone:601-833-1958
Mailing Address - Fax:601-833-3938
Practice Address - Street 1:347 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3219
Practice Address - Country:US
Practice Address - Phone:601-833-1958
Practice Address - Fax:601-833-3938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00089220Medicaid
0280030001Medicare NSC