Healthcare Provider Details

I. General information

NPI: 1255990099
Provider Name (Legal Business Name): MACKENZIE SPEERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MAIN ST
BROOKVILLE IN
47012-1363
US

IV. Provider business mailing address

PO BOX 427
CONNERSVILLE IN
47331-0427
US

V. Phone/Fax

Practice location:
  • Phone: 765-547-1325
  • Fax: 765-547-1327
Mailing address:
  • Phone: 765-825-4127
  • Fax: 765-827-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004158A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: