Provider Demographics
NPI:1730721986
Name:HENNINGS, TIMOTHY LAWRENCE
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LAWRENCE
Last Name:HENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HUNTINGTON ST SPC 313
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5344
Mailing Address - Country:US
Mailing Address - Phone:714-766-9799
Mailing Address - Fax:
Practice Address - Street 1:80 HUNTINGTON ST SPC 313
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-5344
Practice Address - Country:US
Practice Address - Phone:714-766-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASLD5989156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician