Healthcare Provider Details

I. General information

NPI: 1801716048
Provider Name (Legal Business Name): FENWARDEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N STATE ST STE A
JACKSON MS
39202-2627
US

IV. Provider business mailing address

901 N STATE ST STE A
JACKSON MS
39202-2627
US

V. Phone/Fax

Practice location:
  • Phone: 406-309-6462
  • Fax:
Mailing address:
  • Phone: 406-309-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLES BURTON
Title or Position: OWNER
Credential:
Phone: 406-309-6462