Healthcare Provider Details

I. General information

NPI: 1407916919
Provider Name (Legal Business Name): VASILE G FAKLIS CO, BOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 E TARPON AVE
TARPON SPRINGS FL
34689-3451
US

IV. Provider business mailing address

139 E TARPON AVE
TARPON SPRINGS FL
34689-3451
US

V. Phone/Fax

Practice location:
  • Phone: 727-938-1525
  • Fax: 727-938-1669
Mailing address:
  • Phone: 727-938-1525
  • Fax: 727-938-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberORT 84
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: