Healthcare Provider Details

I. General information

NPI: 1417976143
Provider Name (Legal Business Name): WILLIAM FAGAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 MAIN ST
WAILUKU HI
96793-1666
US

IV. Provider business mailing address

2180 MAIN ST
WAILUKU HI
96793-1666
US

V. Phone/Fax

Practice location:
  • Phone: 808-242-6464
  • Fax: 808-984-7442
Mailing address:
  • Phone: 808-242-6464
  • Fax: 808-984-7442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC163
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: