Healthcare Provider Details

I. General information

NPI: 1730151572
Provider Name (Legal Business Name): DENNIS M BRTVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 N VETERANS PKWY STE 2
BLOOMINGTON IL
61704-0910
US

IV. Provider business mailing address

2109 N VETERANS PKWY STE 2
BLOOMINGTON IL
61704-0910
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-2211
  • Fax: 309-664-2971
Mailing address:
  • Phone: 309-663-2211
  • Fax: 309-664-2971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. DENNIS M BRTVA
Title or Position: OWNER
Credential: O.D.
Phone: 309-663-2211