1063511350 NPI number — DR. RICHARD G FENN D.C.

Table of content: DR. RICHARD G FENN D.C. (NPI 1063511350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063511350 NPI number — DR. RICHARD G FENN D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENN
Provider First Name:
RICHARD
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063511350
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1696 SE HILLMOOR DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-7699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
647-402-0303
Provider Business Mailing Address Fax Number:
561-626-3371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10935 SE 177TH PL STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERFIELD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34491-8975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-626-5433
Provider Business Practice Location Address Fax Number:
561-626-3371
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH5263 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 77947 . This is a "BCBS PIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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