Organization
B. MICHAEL SOUTHAM, OD, PC
Active
Other names
Black Rock Vision Center
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRANT MICHAEL SOUTHAM OD (OWNER/PRESIDENT)
(775) 825-0559
Entity
Organization
Contact information
Practice address
3201 LAKESIDE DR, RENO, NV 89509-4830
(775) 825-0559
(775) 829-7918
Mailing address
3201 LAKESIDE DR, RENO, NV 89509-4830
(775) 825-0559
(775) 829-7918
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
779
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100533928
—
NV
Enumeration date
12/18/2013
Last updated
12/18/2013
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