Provider Demographics
NPI:1114220936
Name:L. BROCK WREN OD PLLC
Entity Type:Organization
Organization Name:L. BROCK WREN OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:BROCK
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-376-0893
Mailing Address - Street 1:350 N MILWAUKEE ST
Mailing Address - Street 2:STE 1188
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9123
Mailing Address - Country:US
Mailing Address - Phone:208-376-0893
Mailing Address - Fax:208-376-3029
Practice Address - Street 1:350 N MILWAUKEE ST
Practice Address - Street 2:STE 1188
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9123
Practice Address - Country:US
Practice Address - Phone:208-376-0893
Practice Address - Fax:208-376-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808643800Medicaid