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General NPI Number Information
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NPI Number | 1881945038
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Entity Type | Organization
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Legal Business Name | MENIFEE VALLEY OPTOMETRY PC
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Dates
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Enumeration Date | 09/27/2012
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 27168 NEWPORT RD SUITE 4
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City | MENIFEE
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State | CA
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Zip | 92584-7383
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Country | US
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Telephone | 951-679-0545
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Fax | 951-679-6154
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Provider Business Mailing Address
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Address Line | 27168 NEWPORT RD. SUITE 4
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City | MENIFEE
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State | CA
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Zip | 92584-6526
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Country | US
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Telephone | 951-679-0545
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Fax | 951-679-6154
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Authorized Official
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Title or Position | OWNER
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Name | DR. ERIC M. FENNEMA
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Credential | O.D.
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Telephone | 951-679-0545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT8225TLG
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License Number State | CA
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