Healthcare Provider Details

I. General information

NPI: 1063627297
Provider Name (Legal Business Name): BRIAN M FAGHAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LONG POND RD SUITE 111
PLYMOUTH MA
02360-2642
US

IV. Provider business mailing address

110 LONG POND RD SUITE 111
PLYMOUTH MA
02360-2642
US

V. Phone/Fax

Practice location:
  • Phone: 508-746-6922
  • Fax: 508-746-7211
Mailing address:
  • Phone: 508-746-6922
  • Fax: 508-746-7211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6208
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: