Provider Demographics
NPI:1932744570
Name:BOWEN, BRANDON R (LDO)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:R
Last Name:BOWEN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 E LINCOLN TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1253
Mailing Address - Country:US
Mailing Address - Phone:270-351-5367
Mailing Address - Fax:
Practice Address - Street 1:171 E LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-1253
Practice Address - Country:US
Practice Address - Phone:270-351-5367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110135156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician