Basic Information
| Provider Information | |||||||||
| NPI: | 1033559026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 568 FALLS AVE | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082938580 | ||||||||
| FaxNumber: | 2087121058 | ||||||||
| 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: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 14652 | CA | N | Eye and Vision Services Providers | Optometrist | 152WP0200X | ODP:100311 | ID | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WP0200X | 14652 | CA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WS0006X | ODP:100311 | ID | N | Eye and Vision Services Providers | Optometrist | Sports Vision | 152WV0400X | ODP:100311 | ID | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152WV0400X | 14652 | CA | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152W00000X | ODP:100311 | ID | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.