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General NPI Number Information
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NPI Number | 1093790941
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Entity Type | Individual
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Provider Name | WILFRED JAMES FENNEWALD LICENSED OPTICIAN
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Gender | Male
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Dates
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Enumeration Date | 12/14/2005
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Last Update Date | 01/28/2019
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Provider Practice Location Address
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Address Line | 2737 NAVARRE AVE STE 204
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City | OREGON
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State | OH
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Zip | 43616-3276
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Country | US
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Telephone | 419-693-3376
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Fax | 419-693-7519
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Provider Business Mailing Address
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Address Line | 2737 NAVARRE AVE STE 204
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City | OREGON
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State | OH
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Zip | 43616-3276
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Country | US
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Telephone | 419-693-3376
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Fax | 419-693-7519
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FC0801X
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Taxonomy Name | Contact Lens Fitter
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License Number | SC2077
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | SC2077
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License Number State | OH
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