Provider Demographics
NPI:1144496621
Name:RICHARD M FANELLI
Entity type:Organization
Organization Name:RICHARD M FANELLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-243-8003
Mailing Address - Street 1:397 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:397 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3119
Practice Address - Country:US
Practice Address - Phone:860-243-8003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT05777156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0385140001Medicare NSC