Healthcare Provider Details

I. General information

NPI: 1487702254
Provider Name (Legal Business Name): DAVID LEE FAIRBANKS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 9TH ST
GLADSTONE MI
49837-1613
US

IV. Provider business mailing address

510 S 9TH ST
GLADSTONE MI
49837-1613
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-1679
  • Fax: 906-428-4643
Mailing address:
  • Phone: 906-428-1679
  • Fax: 906-428-4643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301005132
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: