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General NPI Number Information
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NPI Number | 1912259441
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Entity Type | Organization
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Legal Business Name | ROBERTA L. FENNIG DO PC
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Dates
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Enumeration Date | 10/08/2012
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Last Update Date | 10/08/2012
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Provider Practice Location Address
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Address Line | 5305 MCNUTT RD SUITE H
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City | SANTA TERESA
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State | NM
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Zip | 88008-9685
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Country | US
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Telephone | 575-589-1770
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Fax | 575-589-1799
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Provider Business Mailing Address
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Address Line | PO BOX 4
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City | SANTA TERESA
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State | NM
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Zip | 88008-0004
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Country | US
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Telephone | 575-589-1770
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Fax | 575-589-1799
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERTA LEE FENNIG
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Credential | DO
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Telephone | 915-494-1237
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | A167712
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License Number State | NM
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