| Name: | Dr. Charles J. Brazeal, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Foreign Professional Corporation |
| Status: | Withdrawn |
| Entity Number: | 000-883-244 |
| Register Number: | 000883244 |
| County: | Chambers |
| Place of Formation: | Georgia |
| Principal Address: | 300 E EIGHT STREETWEST POINT, GA 31833 |
| Registered Office Street Address: | 308 13TH AVE SLANETT, AL 36863 |
| Registered Office Street Address ZIP Code: | 36863 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1982757480 | 2007-01-19 | 2014-03-14 | 950 HIGHWAY 431 STE 4, ROANOKE, AL, 362747314, US | 950 HIGHWAY 431 STE 4, ROANOKE, AL, 362747314, US | |||||||||||||||||||||||||
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| Phone | +1 334-863-2221 |
| Fax | 3348632319 |
Authorized person
| Name | MS. DAWN NORTON |
| Role | OFFICE MANAGER |
| Phone | 3348632221 |
Taxonomy
| Taxonomy Code | 152W00000X - Optometrist |
| License Number | S407TA017 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 126302 |
| State | AL |
| Name | Role |
|---|---|
| BRAZEAL, CHARLES J | Agent |
Date of last update: 16 Aug 2024
Sources: Alabama Secretary of State
