Healthcare Provider Details

I. General information

NPI: 1568636207
Provider Name (Legal Business Name): BRENT W FIDLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 W EISENHOWER BLVD STE. C
LOVELAND CO
80537-3112
US

IV. Provider business mailing address

1524 W EISENHOWER BLVD STE. C
LOVELAND CO
80537-3112
US

V. Phone/Fax

Practice location:
  • Phone: 970-667-2954
  • Fax: 970-663-4713
Mailing address:
  • Phone: 970-667-2954
  • Fax: 970-663-4713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. BRENT W. FIDLER
Title or Position: OWNER
Credential: O.D.
Phone: 970-667-2954