Basic Information
| Provider Information | |||||||||
| NPI: | 1194769844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1530 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804021530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036536255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 952 SWEDE GULCH RD | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804393713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035260534 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WL0500X | 2339 | CO | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152W00000X | 2339 | CO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.