Provider Demographics
NPI:1790059962
Name:FONDREN, ANTHONY (LMT)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:FONDREN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2049 TREMAINSVILLE RD
Mailing Address - Street 2:#2
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-3969
Mailing Address - Country:US
Mailing Address - Phone:419-345-0195
Mailing Address - Fax:
Practice Address - Street 1:4405 N HOLLAND SYLVANIA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3529
Practice Address - Country:US
Practice Address - Phone:419-345-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17917225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist