MEDICARE: BROOKE PLAZA OPTICAL, INC.

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	152W00000X	Optometrist	VUT2830-1	NY

General Provider Information

NPI Number	:	1467620708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKE PLAZA OPTICAL, INC.

Provider Business Mailing Address
First Line	:	3450 LONG BEACH RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-5440
Country	:	US
Telephone Number	:	516-678-1616
Fax Number	:	516-764-2711

Provider Business Practice Location Address
First Line	:	3450 LONG BEACH RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-5440
Country	:	US
Telephone Number	:	516-678-1616
Fax Number	:	516-764-2711

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD BOHN
Credential	:	OD
Telephone Number	:	516-678-1616

Provider Enumeration Date	:	02/20/2008
Last Update Date	:	05/19/2009

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