Healthcare Provider Details

I. General information

NPI: 1043887144
Provider Name (Legal Business Name): RONALD B FAIRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 BOYD DR
NASHVILLE TN
37218-1609
US

IV. Provider business mailing address

4921 BOYD DR
NASHVILLE TN
37218-1609
US

V. Phone/Fax

Practice location:
  • Phone: 615-707-3543
  • Fax:
Mailing address:
  • Phone: 615-707-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number66913872
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: