Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SC 2197 | OH |
NPI | 1083007587 |
---|---|
Provider Name | Richard Fennig |
First Address | Centerville, OH 45459-2753 |
Second Address | Centerville, OH 45459-2789 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2015 |
Last Update Date | 09/03/2015 |