MEDICARE: LACEY B BRENNER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	OEG002404	PA
2	152W00000X	Optometrist	0002932	CO

General Provider Information

NPI Number	:	1508162710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY B BRENNER OD

Provider Business Mailing Address
First Line	:	5850 ROY HTS
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1593
Country	:	US
Telephone Number	:	785-821-0499
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 MAX DR
Second Line	:	SUITE 101
City	:	CASTLE PINES
State	:	CO
Zip	:	80108-9517
Country	:	US
Telephone Number	:	303-688-5066
Fax Number	:	303-688-6986

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	05/28/2015

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