Healthcare Provider Details

I. General information

NPI: 1700884996
Provider Name (Legal Business Name): BRIAN C FENNEN LAC, QME
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 WASHINGTON ST
CALISTOGA CA
94515-1439
US

IV. Provider business mailing address

1217 WASHINGTON ST
CALISTOGA CA
94515-1439
US

V. Phone/Fax

Practice location:
  • Phone: 707-942-9380
  • Fax: 707-942-8242
Mailing address:
  • Phone: 707-942-9380
  • Fax: 707-942-8242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number3537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: