Provider Demographics
NPI:1083007587
Name:FENNIG, RICHARD (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:FENNIG
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E ALEX BELL RD
Mailing Address - Street 2:#120
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2753
Mailing Address - Country:US
Mailing Address - Phone:937-435-2437
Mailing Address - Fax:937-435-9579
Practice Address - Street 1:101 E ALEX-BELL RD #120
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2789
Practice Address - Country:US
Practice Address - Phone:937-435-2437
Practice Address - Fax:937-435-9579
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC 2197156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician