Provider Demographics
NPI:1003858457
Name:BRENOT, FABRICE (OD)
Entity Type:Individual
Prefix:MR
First Name:FABRICE
Middle Name:
Last Name:BRENOT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HITCHCOCK WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-4125
Mailing Address - Country:US
Mailing Address - Phone:603-695-2500
Mailing Address - Fax:
Practice Address - Street 1:5 COLISEUM AVE STE 101
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3292
Practice Address - Country:US
Practice Address - Phone:603-882-9800
Practice Address - Fax:603-882-0556
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH 0704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30351916Medicaid
NH3076155Medicaid
NH30351916Medicaid