Healthcare Provider Details

I. General information

NPI: 1669877098
Provider Name (Legal Business Name): CHILDREN'S CLEAR VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
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: 208-284-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100311
License Number StateID

VIII. Authorized Official

Name: BRANDON CLARK NIELSEN
Title or Position: OPTOMETRIST
Credential: OD
Phone: 208-284-0650