Provider Demographics
NPI: | 1437248267 |
---|---|
Name: | BRAGA, ANN RENE (OPTICIAN) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | ANN |
Middle Name: | RENE |
Last Name: | BRAGA |
Suffix: | |
Gender: | F |
Credentials: | OPTICIAN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 691 SHOSHONE ST N |
Mailing Address - Street 2: | |
Mailing Address - City: | TWIN FALLS |
Mailing Address - State: | ID |
Mailing Address - Zip Code: | 83301-6154 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 208-733-1067 |
Mailing Address - Fax: | 208-733-7597 |
Practice Address - Street 1: | 691 SHOSHONE ST N |
Practice Address - Street 2: | |
Practice Address - City: | TWIN FALLS |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83301-6154 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-733-1067 |
Practice Address - Fax: | 208-733-7597 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-10-12 |
Last Update Date: | 2008-06-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ID | OD485 | 152W00000X |
AZ | 601I | 156FX1800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | |
No | 156FX1800X | Eye and Vision Services Providers | Technician/Technologist | Optician |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ID | V2894 | Other | BLUE CROSS |
ID | 000010014411 | Other | BLUE SHIELD |
ID | V2894 | Other | BLUE CROSS |