MEDICARE: RICHARD M FANELLI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	05777	CT

General Provider Information

NPI Number	:	1144496621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD M FANELLI

Provider Business Mailing Address
First Line	:	397 COTTAGE GROVE RD
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	397 COTTAGE GROVE RD
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3119
Country	:	US
Telephone Number	:	860-243-8003
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RICHARD FANELLI
Credential	:
Telephone Number	:	860-243-8003

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	07/11/2008

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