Provider Demographics
NPI:1912259441
Name:ROBERTA L. FENNIG DO PC
Entity Type:Organization
Organization Name:ROBERTA L. FENNIG DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FENNIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:915-494-1237
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-0004
Mailing Address - Country:US
Mailing Address - Phone:575-589-1770
Mailing Address - Fax:575-589-1799
Practice Address - Street 1:5305 MCNUTT RD
Practice Address - Street 2:SUITE H
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9685
Practice Address - Country:US
Practice Address - Phone:575-589-1770
Practice Address - Fax:575-589-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA167712261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center