MEDICARE: HENDERSON OPTICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083791354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENDERSON OPTICAL, LLC

Provider Business Mailing Address
First Line	:	1201 SUMMIT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-4413
Country	:	US
Telephone Number	:	817-336-3653
Fax Number	:	817-332-4233

Provider Business Practice Location Address
First Line	:	1201 SUMMIT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-4413
Country	:	US
Telephone Number	:	817-336-3653
Fax Number	:	817-332-4233

Authorized Official
Title or Position	:	OPHTHALMOLOGIST
Name	:	DAN BRUHL
Credential	:	M.D.
Telephone Number	:	817-336-3653

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	03/04/2020

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Directions to “HENDERSON OPTICAL, LLC ” Practice Location

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