Provider Demographics
NPI:1316162019
Name:BEREA OPTICAL LLC
Entity type:Organization
Organization Name:BEREA OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBA
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-985-0044
Mailing Address - Street 1:400 RICHMOND RD N
Mailing Address - Street 2:SUITE F
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1015
Mailing Address - Country:US
Mailing Address - Phone:859-985-0044
Mailing Address - Fax:859-985-0045
Practice Address - Street 1:400 RICHMOND RD N
Practice Address - Street 2:STE. F
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1015
Practice Address - Country:US
Practice Address - Phone:859-985-0044
Practice Address - Fax:859-985-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 1075156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY 1075OtherEYEMED
KY52000130Medicaid