Provider Demographics
NPI:1376811489
Name:FENTON, JOHN M III (CPO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:FENTON
Suffix:III
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 RACHEL ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1721
Mailing Address - Country:US
Mailing Address - Phone:417-732-8483
Mailing Address - Fax:417-732-8902
Practice Address - Street 1:838 RACHEL ST
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1721
Practice Address - Country:US
Practice Address - Phone:417-732-8483
Practice Address - Fax:417-732-8902
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier