Healthcare Provider Details

I. General information

NPI: 1962808683
Provider Name (Legal Business Name): MICHAEL FAFINSKI LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6417 ODANA RD SUITE 4B
MADISON WI
53719-1128
US

IV. Provider business mailing address

4725 TOKAY BLVD
MADISON WI
53711-1360
US

V. Phone/Fax

Practice location:
  • Phone: 608-843-6408
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2651-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: