Provider Demographics
NPI:1619024601
Name:HANNEGAN, COLLEEN (RDO)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:HANNEGAN
Suffix:
Gender:F
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21098 BAKE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2163
Mailing Address - Country:US
Mailing Address - Phone:949-597-0104
Mailing Address - Fax:949-597-0106
Practice Address - Street 1:21098 BAKE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2163
Practice Address - Country:US
Practice Address - Phone:949-597-0104
Practice Address - Fax:949-597-0106
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL 1762156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1048700001Medicare NSC