Provider Demographics
NPI:1265996441
Name:DR HEIDI FENNELL A CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:DR HEIDI FENNELL A CHIROPRACTIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:A
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-415-6948
Mailing Address - Street 1:230 N MARYLAND AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4281
Mailing Address - Country:US
Mailing Address - Phone:818-415-6948
Mailing Address - Fax:
Practice Address - Street 1:230 N MARYLAND AVE STE 309
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4281
Practice Address - Country:US
Practice Address - Phone:818-415-6948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1609969120OtherNOT APPLICABLE