Provider Demographics
NPI:1700884996
Name:FENNEN, BRIAN C (LAC, QME)
Entity Type:Individual
Prefix:PROF
First Name:BRIAN
Middle Name:C
Last Name:FENNEN
Suffix:
Gender:M
Credentials:LAC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CALISTOGA
Mailing Address - State:CA
Mailing Address - Zip Code:94515-1439
Mailing Address - Country:US
Mailing Address - Phone:707-942-9380
Mailing Address - Fax:707-942-8242
Practice Address - Street 1:1217 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1439
Practice Address - Country:US
Practice Address - Phone:707-942-9380
Practice Address - Fax:707-942-8242
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3537171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist