Provider Demographics
NPI:1194178038
Name:FAHRENHOLZ, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:FAHRENHOLZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 N TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-4743
Mailing Address - Country:US
Mailing Address - Phone:813-872-6250
Mailing Address - Fax:
Practice Address - Street 1:3809 N TAMPA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-4743
Practice Address - Country:US
Practice Address - Phone:813-872-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities