Provider Demographics
NPI:1881160992
Name:FENNERN, RON
Entity type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:FENNERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BRUTSCHER ST STE 208
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6097
Mailing Address - Country:US
Mailing Address - Phone:503-538-0100
Mailing Address - Fax:
Practice Address - Street 1:901 BRUTSCHER ST STE 208
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6097
Practice Address - Country:US
Practice Address - Phone:503-538-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR17659OtherOREGON BOARD OF MASSAGE THERAPY
OR18540OtherOREGON BOARD OF MASSAGE THERAPY
OR21602OtherOREGON BOARD OF MASSAGE THERAPY
OR23534OtherOREGON BOARD OF MASSAGE THERAPY
OR11904OtherOREGON BOARD OF MASSAGE THERAPY