Provider Demographics
NPI:1700676558
Name:BROOKHAVEN VISION CARE, LLC
Entity type:Organization
Organization Name:BROOKHAVEN VISION CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OD
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-728-7588
Mailing Address - Street 1:5265 WHITEHAVEN PARK LN SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5938
Mailing Address - Country:US
Mailing Address - Phone:704-728-7588
Mailing Address - Fax:
Practice Address - Street 1:500 BROOKHAVEN AVE NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3291
Practice Address - Country:US
Practice Address - Phone:704-728-7588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty