MEDICARE: MR. BRANT WILLIAM FECHTER OPTOMETRY TECH

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	156FX1202X	Optometric Technician

General Provider Information

NPI Number	:	1891002010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANT WILLIAM FECHTER OPTOMETRY TECH

Provider Business Mailing Address
First Line	:	126 MISSOURI AVE., EENT CLINIC
Second Line	:	JENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473
Country	:	US
Telephone Number	:	573-596-0131
Fax Number	:	573-596-0086

Provider Business Practice Location Address
First Line	:	123 MISSOURI AVE., EENT CLINIC
Second Line	:	JENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473
Country	:	US
Telephone Number	:	573-596-0131
Fax Number	:	573-596-0086

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

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	09/09/2010

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