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General NPI Number Information
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NPI Number | 1104240340
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Entity Type | Organization
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Legal Business Name | FATA INC.
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Dates
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Enumeration Date | 02/07/2014
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Last Update Date | 02/07/2014
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Provider Practice Location Address
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Address Line | 9773 SIERRA AVE 9773 SIERRA AVE. #H7
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City | FONTANA
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State | CA
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Zip | 92335-6716
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Country | US
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Telephone | 909-829-2349
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Fax | 909-829-2349
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Provider Business Mailing Address
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Address Line | 9773 SIERRA AVE 9773 SIERRA AVE. #H7
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City | FONTANA
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State | CA
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Zip | 92335-6716
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Country | US
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Telephone | 909-829-2349
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Fax | 909-829-2349
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Authorized Official
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Title or Position | MANAGER
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Name | MR. SOON PARK
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Credential | D.AC.
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Telephone | 909-829-2349
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZA2600X
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Taxonomy Name | Medical Art Specialist/Technologist
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License Number | AC12047
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License Number State | CA
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