Provider Demographics
NPI:1568743227
Name:FENNELLY, SAMPSON RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMPSON
Middle Name:RICHARD
Last Name:FENNELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WHITEFISH STAGE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2172
Mailing Address - Country:US
Mailing Address - Phone:406-755-3014
Mailing Address - Fax:406-755-3214
Practice Address - Street 1:1600 WHITEFISH STAGE
Practice Address - Street 2:SUITE 1
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2172
Practice Address - Country:US
Practice Address - Phone:406-755-3014
Practice Address - Fax:406-755-3214
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1255111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor