Healthcare Provider Details

I. General information

NPI: 1720055882
Provider Name (Legal Business Name): FAIRMONT ENT ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 LOCUST AVE
FAIRMONT WV
26554
US

IV. Provider business mailing address

1712 LOCUST AVE
FAIRMONT WV
26554
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-6157
  • Fax: 304-366-0177
Mailing address:
  • Phone: 304-366-6157
  • Fax: 304-366-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number398
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberWV14772
License Number StateWV

VIII. Authorized Official

Name: DR. JOEDY L DARISTOTLE
Title or Position: PRESIDENT
Credential: MD
Phone: 304-366-6157