Basic Information
Provider Information
NPI: 1033559026
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NIELSEN
FirstName: BRANDON
MiddleName: CLARK
NamePrefix: DR.
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 568 FALLS AVE
Address2:  
City: TWIN FALLS
State: ID
PostalCode: 833013314
CountryCode: US
TelephoneNumber: 2082840650
FaxNumber:  
Practice Location
Address1: 568 FALLS AVE
Address2:  
City: TWIN FALLS
State: ID
PostalCode: 833013314
CountryCode: US
TelephoneNumber: 2082840650
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/05/2013
LastUpdateDate: 10/28/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X14652CAN Eye and Vision Services ProvidersOptometrist 
152W00000XODP:100311IDY Eye and Vision Services ProvidersOptometrist 
152WP0200X14652CAN Eye and Vision Services ProvidersOptometristPediatrics
152WP0200XODP:100311IDN Eye and Vision Services ProvidersOptometristPediatrics
152WS0006XODP:100311IDN Eye and Vision Services ProvidersOptometristSports Vision
152WV0400X14652CAN Eye and Vision Services ProvidersOptometristVision Therapy
152WV0400XODP:100311IDN Eye and Vision Services ProvidersOptometristVision Therapy

No ID Information.


Home