Provider Demographics
NPI:1801171293
Name:DR WENDELL R FACKRELL PLLC
Entity type:Organization
Organization Name:DR WENDELL R FACKRELL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:FACKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:801-722-5380
Mailing Address - Street 1:4145 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4145 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2421
Practice Address - Country:US
Practice Address - Phone:801-722-5380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty