MEDICARE: DR. BRYCE FENNELL D.C.

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	111N00000X	Chiropractor	7415	CO

General Provider Information

NPI Number	:	1215478532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYCE FENNELL D.C.

Provider Business Mailing Address
First Line	:	1301 RIVERSIDE AVE STE 2
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-4374
Country	:	US
Telephone Number	:	970-493-4049
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 RIVERSIDE AVE STE 2
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-4374
Country	:	US
Telephone Number	:	970-493-4049
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2017
Last Update Date	:	03/20/2017

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