Provider Demographics
NPI:1891581435
Name:RENNELLS, DALE
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:RENNELLS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 S 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6150 S 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5004
Practice Address - Country:US
Practice Address - Phone:602-243-8523
Practice Address - Fax:602-243-8525
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLDO002227156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician