Provider Demographics
NPI:1679878524
Name:OPTIQUE AT BROOKHAVEN, LLC
Entity type:Organization
Organization Name:OPTIQUE AT BROOKHAVEN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:404-844-1500
Mailing Address - Street 1:305 BROOKHAVEN AVE
Mailing Address - Street 2:SW 1110
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-4316
Mailing Address - Country:US
Mailing Address - Phone:404-816-8889
Mailing Address - Fax:404-816-8890
Practice Address - Street 1:305 BROOKHAVEN AVE
Practice Address - Street 2:SW 1110
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-4316
Practice Address - Country:US
Practice Address - Phone:404-816-8889
Practice Address - Fax:404-816-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPTOO2338152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty