Provider Demographics
NPI:1508162710
Name:BRENNER, LACEY B (OD)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:B
Last Name:BRENNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 ROY HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1593
Mailing Address - Country:US
Mailing Address - Phone:785-821-0499
Mailing Address - Fax:
Practice Address - Street 1:250 MAX DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CASTLE PINES
Practice Address - State:CO
Practice Address - Zip Code:80108-9517
Practice Address - Country:US
Practice Address - Phone:303-688-5066
Practice Address - Fax:303-688-6986
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002404390200000X
CO0002932152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program