Healthcare Provider Details

I. General information

NPI: 1891002069
Provider Name (Legal Business Name): KENT CHRISTIAN FAIRBOURN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 W 200 N
SAINT GEORGE UT
84770-4505
US

IV. Provider business mailing address

1901 E 10 NORTH CIR
SAINT GEORGE UT
84790-1585
US

V. Phone/Fax

Practice location:
  • Phone: 435-634-5600
  • Fax:
Mailing address:
  • Phone: 435-668-7795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: