Provider Demographics
NPI:1386743813
Name:FENN, RICHARD FOY (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:FOY
Last Name:FENN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BOLL WEEVIL CIR
Mailing Address - Street 2:WAL-MART VISON CENTER 734
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2715
Mailing Address - Country:US
Mailing Address - Phone:334-347-4144
Mailing Address - Fax:334-347-4397
Practice Address - Street 1:600 BOLL WEEVIL CIR
Practice Address - Street 2:WAL-MART VISON CENTER 734
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2715
Practice Address - Country:US
Practice Address - Phone:334-347-4144
Practice Address - Fax:334-347-4397
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS922 TA489152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00045865FENMedicare ID - Type Unspecified
ALU76634Medicare UPIN