Healthcare Provider Details

I. General information

NPI: 1760490494
Provider Name (Legal Business Name): BROOKHAVEN FAMILY EYE CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 EDGMONT AVE
BROOKHAVEN PA
19015-2314
US

IV. Provider business mailing address

4106 EDGMONT AVE
BROOKHAVEN PA
19015-2314
US

V. Phone/Fax

Practice location:
  • Phone: 610-872-8989
  • Fax: 610-872-5220
Mailing address:
  • Phone: 610-872-8989
  • Fax: 610-872-5220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001547
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOEG001547
License Number StatePA

VIII. Authorized Official

Name: MICAELA L SMALL
Title or Position: PRESIDENT
Credential: OD
Phone: 610-872-8989