Healthcare Provider Details

I. General information

NPI: 1528361805
Provider Name (Legal Business Name): MRS. BRENDA L TIBBETTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRENDA L DIMITROPOLIS/BRESSEM

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MAIN ST STE E
MONSON MA
01057-1353
US

IV. Provider business mailing address

170 MAIN ST STE E
MONSON MA
01057-1353
US

V. Phone/Fax

Practice location:
  • Phone: 413-267-4200
  • Fax: 413-267-4200
Mailing address:
  • Phone: 413-267-4200
  • Fax: 413-267-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number5499
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: