Healthcare Provider Details

I. General information

NPI: 1093790941
Provider Name (Legal Business Name): WILFRED JAMES FENNEWALD LICENSED OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. W JAMES FENNEWALD

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 NAVARRE AVE STE 204
OREGON OH
43616-3276
US

IV. Provider business mailing address

2737 NAVARRE AVE STE 204
OREGON OH
43616-3276
US

V. Phone/Fax

Practice location:
  • Phone: 419-693-3376
  • Fax: 419-693-7519
Mailing address:
  • Phone: 419-693-3376
  • Fax: 419-693-7519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License NumberSC2077
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberSC2077
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: