Healthcare Provider Details

I. General information

NPI: 1457225633
Provider Name (Legal Business Name): FAGVA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 NE 4TH CT
BOCA RATON FL
33432-2811
US

IV. Provider business mailing address

1305 NE 4TH CT
BOCA RATON FL
33432-2811
US

V. Phone/Fax

Practice location:
  • Phone: 305-615-9294
  • Fax:
Mailing address:
  • Phone: 305-615-9294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: RUSTAM BAKHATIIAROV
Title or Position: PRESIDENT
Credential:
Phone: 305-615-9294