Healthcare Provider Details

I. General information

NPI: 1679878524
Provider Name (Legal Business Name): OPTIQUE AT BROOKHAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 BROOKHAVEN AVE SW 1110
ATLANTA GA
30319-4316
US

IV. Provider business mailing address

305 BROOKHAVEN AVE SW 1110
ATLANTA GA
30319-4316
US

V. Phone/Fax

Practice location:
  • Phone: 404-816-8889
  • Fax: 404-816-8890
Mailing address:
  • Phone: 404-816-8889
  • Fax: 404-816-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPTOO2338
License Number StateGA

VIII. Authorized Official

Name: GAVIN COHEN
Title or Position: PRESIDENT
Credential: OD
Phone: 404-844-1500