Healthcare Provider Details

I. General information

NPI: 1679334411
Provider Name (Legal Business Name): BRENDAN OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3164 BERLIN TPKE
NEWINGTON CT
06111-4627
US

IV. Provider business mailing address

3164 BERLIN TPKE
NEWINGTON CT
06111-4627
US

V. Phone/Fax

Practice location:
  • Phone: 860-667-8867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1689
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: