Healthcare Provider Details

I. General information

NPI: 1669664702
Provider Name (Legal Business Name): MRS. MARLEN A FAJO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 NW 36TH ST SUITE 200
VIRGINIA GARDENS FL
33166-6978
US

IV. Provider business mailing address

6555 NW 36TH ST SUITE 200
VIRGINIA GARDENS FL
33166-6978
US

V. Phone/Fax

Practice location:
  • Phone: 305-871-2238
  • Fax: 305-871-2281
Mailing address:
  • Phone: 305-871-2238
  • Fax: 305-871-2281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 43909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: