Healthcare Provider Details

I. General information

NPI: 1669953873
Provider Name (Legal Business Name): BRETT MICHAEL HOLLENBACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2018
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MCNAUGHTEN RD
COLUMBUS OH
43213-2120
US

IV. Provider business mailing address

2180 TROOP DR
SARTELL MN
56377-4563
US

V. Phone/Fax

Practice location:
  • Phone: 847-293-6906
  • Fax:
Mailing address:
  • Phone: 320-258-3915
  • Fax: 320-258-3917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3647
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: