Provider Demographics
NPI:1700130952
Name:DR. CRAIG A. FENIMORE, OPTOMETRIST
Entity Type:Organization
Organization Name:DR. CRAIG A. FENIMORE, OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELLODY
Authorized Official - Middle Name:FERN
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-932-4800
Mailing Address - Street 1:1818 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-9316
Mailing Address - Country:US
Mailing Address - Phone:765-932-4800
Mailing Address - Fax:765-932-2619
Practice Address - Street 1:1818 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-9316
Practice Address - Country:US
Practice Address - Phone:765-932-4800
Practice Address - Fax:765-932-2619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002225332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0138200001Medicare NSC