Provider Demographics
NPI:1649441445
Name:FENNEMAN, ROGER LEE (LAC)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:LEE
Last Name:FENNEMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 N MAIN ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3201
Mailing Address - Country:US
Mailing Address - Phone:928-852-7275
Mailing Address - Fax:928-852-7275
Practice Address - Street 1:687 N MAIN ST UNIT A
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3201
Practice Address - Country:US
Practice Address - Phone:928-852-7275
Practice Address - Fax:928-852-7275
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ555171100000X
AZ0555171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist