Healthcare Provider Details

I. General information

NPI: 1972913234
Provider Name (Legal Business Name): KHAILITHA FAE L. AC, DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 GARDEN ST STE B
PRESCOTT AZ
86305-2913
US

IV. Provider business mailing address

1539 OREGON AVE
PRESCOTT AZ
86305-2225
US

V. Phone/Fax

Practice location:
  • Phone: 928-225-1655
  • Fax:
Mailing address:
  • Phone: 928-225-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0780
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1020
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: