Healthcare Provider Details

I. General information

NPI: 1770740482
Provider Name (Legal Business Name): FAGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 INDEPENDENCE DR SUITE 300A
BIRMINGHAM AL
35209-4159
US

IV. Provider business mailing address

3125 INDEPENDENCE DR SUITE 300A
BIRMINGHAM AL
35209-4159
US

V. Phone/Fax

Practice location:
  • Phone: 205-879-8206
  • Fax: 205-879-0675
Mailing address:
  • Phone: 205-879-8206
  • Fax: 205-879-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number14105
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number14105
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number14105
License Number StateAL

VIII. Authorized Official

Name: DR. KIMBERLY M FAGAN
Title or Position: DOCTOR/OWNER
Credential: M.D.
Phone: 205-879-8206