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General NPI Number Information
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NPI Number | 1154457612
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Entity Type | Individual
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Provider Name | PETER MICHAEL FANTINO L.M.T.
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Gender | Male
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1110 E STATE ST
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City | FREMONT
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State | OH
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Zip | 43420-4358
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Country | US
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Telephone | 419-307-1290
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Fax | 419-332-1668
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Provider Business Mailing Address
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Address Line | 709 FRANKLIN AVE
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City | FREMONT
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State | OH
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Zip | 43420-2003
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Country | US
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Telephone | 419-332-1668
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Fax | 419-332-1668
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 33.011903
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License Number State | OH
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