Provider Demographics
NPI:1083808562
Name:PHILIP WREN, O.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PHILIP WREN, O.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-979-1550
Mailing Address - Street 1:620 11TH ST
Mailing Address - Street 2:UNIT 202
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-0704
Mailing Address - Country:US
Mailing Address - Phone:303-979-1550
Mailing Address - Fax:303-979-1850
Practice Address - Street 1:8501 W BOWLES AVE
Practice Address - Street 2:STE 1B-204
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-9502
Practice Address - Country:US
Practice Address - Phone:303-979-1550
Practice Address - Fax:303-979-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12089T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18120OtherMEDICARE GROUP PROVIDER #