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General NPI Number Information
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NPI Number | 1760490494
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Entity Type | Organization
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Legal Business Name | BROOKHAVEN FAMILY EYE CARE CENTER
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 05/14/2024
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Provider Practice Location Address
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Address Line | 4106 EDGMONT AVE
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City | BROOKHAVEN
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State | PA
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Zip | 19015-2314
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Country | US
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Telephone | 610-872-8989
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Fax | 610-872-5220
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Provider Business Mailing Address
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Address Line | 4106 EDGMONT AVE
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City | BROOKHAVEN
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State | PA
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Zip | 19015-2314
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Country | US
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Telephone | 610-872-8989
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Fax | 610-872-5220
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICAELA L SMALL
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Credential | OD
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Telephone | 610-872-8989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | OEG001547
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OEG001547
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License Number State | PA
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