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General NPI Number Information
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NPI Number | 1942307053
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Entity Type | Individual
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Provider Name | BRANT TREGELLAS MOLENAAR OD
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Gender | Male
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 11/13/2025
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Provider Practice Location Address
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Address Line | 3546 RIDGE ROAD
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City | LANSING
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State | IL
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Zip | 60438
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Country | US
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Telephone | 708-474-0078
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Fax | 708-474-0141
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Provider Business Mailing Address
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Address Line | 3546 RIDGE RD
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City | LANSING
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State | IL
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Zip | 60438-3146
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Country | US
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Telephone | 708-474-0078
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Fax | 708-474-0141
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | T1494
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18002644
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 46008622
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License Number State | IL
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