Healthcare Provider Details

I. General information

NPI: 1629475744
Provider Name (Legal Business Name): DAN FAGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 TURKEY CRK
ALACHUA FL
32615-9303
US

IV. Provider business mailing address

482 TURKEY CRK
ALACHUA FL
32615-9303
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-3261
  • Fax:
Mailing address:
  • Phone: 602-888-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 72389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: