MEDICARE: PROF. BRIAN C FENNEN LAC, QME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	3537	CA

General Provider Information

NPI Number	:	1700884996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. BRIAN C FENNEN LAC, QME

Provider Business Mailing Address
First Line	:	1217 WASHINGTON ST
Second Line	:
City	:	CALISTOGA
State	:	CA
Zip	:	94515-1439
Country	:	US
Telephone Number	:	707-942-9380
Fax Number	:	707-942-8242

Provider Business Practice Location Address
First Line	:	1217 WASHINGTON ST
Second Line	:
City	:	CALISTOGA
State	:	CA
Zip	:	94515-1439
Country	:	US
Telephone Number	:	707-942-9380
Fax Number	:	707-942-8242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/08/2007

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