Provider Demographics
NPI:1760489868
Name:FENTON, JAMES R (CPO)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:R
Last Name:FENTON
Suffix:
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 1:1701 SE HILLMOOR DR C-13
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7552
Mailing Address - Country:US
Mailing Address - Phone:772-337-7378
Mailing Address - Fax:772-337-1742
Practice Address - Street 1:1701 SE HILLMOOR DR C-13
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7552
Practice Address - Country:US
Practice Address - Phone:772-337-7378
Practice Address - Fax:772-337-1742
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR61222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1226360001Medicare ID - Type Unspecified