Provider Demographics
NPI:1164559084
Name:H JACK FENNEL O.D.
Entity Type:Organization
Organization Name:H JACK FENNEL O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:H.
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:FENNEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-527-2211
Mailing Address - Street 1:1031 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1031 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-2746
Practice Address - Country:US
Practice Address - Phone:530-527-2211
Practice Address - Fax:530-527-7412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5114T152W00000X
CA8189T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081890Medicaid
CASD0051140Medicaid
CASD0051140Medicare ID - Type Unspecified
CAU63174Medicare UPIN
CAT09874Medicare UPIN
CASD0081890Medicare ID - Type Unspecified
CASD0051140Medicaid