Healthcare Provider Details

I. General information

NPI: 1245003706
Provider Name (Legal Business Name): DARYL FAJARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7819 WAYNETOWNE BLVD
HUBER HEIGHTS OH
45424-2063
US

IV. Provider business mailing address

16331 FAIRFIELD LN
GRANGER IN
46530-9572
US

V. Phone/Fax

Practice location:
  • Phone: 937-938-1583
  • Fax:
Mailing address:
  • Phone: 269-815-2419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05014807A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP032188T
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP025952T
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: