Healthcare Provider Details

I. General information

NPI: 1821080250
Provider Name (Legal Business Name): BROOKHAVEN OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 W CHEROKEE ST
BROOKHAVEN MS
39601-3219
US

IV. Provider business mailing address

347 W CHEROKEE ST
BROOKHAVEN MS
39601-3219
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-1958
  • Fax: 601-833-3938
Mailing address:
  • Phone: 601-833-1958
  • Fax: 601-833-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. NATLIE BROWN HERNDON
Title or Position: PRESIDENT
Credential: M.S., PH.D.
Phone: 601-833-1958