Healthcare Provider Details

I. General information

NPI: 1740530088
Provider Name (Legal Business Name): DR FAZZIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 COLLEGE RD SUITE 8B-1
FAIRBANKS AK
99701-1739
US

IV. Provider business mailing address

29 COLLEGE RD SUITE 8B-1
FAIRBANKS AK
99701-1739
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-3302
  • Fax: 907-374-8060
Mailing address:
  • Phone: 907-456-3302
  • Fax: 907-374-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number166
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LEON FAZZIO III
Title or Position: OWNER
Credential: CHIROPRACTOR
Phone: 907-456-3302