1629358411 NPI number — MICHAEL K FAIRBANKS DPM A PROFESSIONAL CORPORATION

Table of content: (NPI 1629358411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629358411 NPI number — MICHAEL K FAIRBANKS DPM A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL K FAIRBANKS DPM A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629358411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7750 EASTRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91941-7882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-465-4972
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 W BONITA AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SAN DIMAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91773-2541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-599-0981
Provider Business Practice Location Address Fax Number:
909-592-0738
Provider Enumeration Date:
08/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FAIRBANKS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
619-465-4972

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E2726 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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