Healthcare Provider Details

I. General information

NPI: 1033559026
Provider Name (Legal Business Name): BRANDON CLARK NIELSEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

568 FALLS AVE
TWIN FALLS ID
83301-3314
US

IV. Provider business mailing address

568 FALLS AVE
TWIN FALLS ID
83301-3314
US

V. Phone/Fax

Practice location:
  • Phone: 208-284-0650
  • Fax:
Mailing address:
  • Phone: 208-293-8580
  • Fax: 208-712-1058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14652
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberODP:100311
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number14652
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberODP:100311
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberODP:100311
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number14652
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP:100311
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: