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General NPI Number Information
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NPI Number | 1265733356
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Entity Type | Organization
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Legal Business Name | AMELIA FAJARDO FAMILY MEDICAL CLINIC PC
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Dates
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Enumeration Date | 11/05/2010
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Last Update Date | 05/11/2011
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Provider Practice Location Address
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Address Line | 450 MEDICAL PARK DR SUITE 100
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City | WATERVLIET
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State | MI
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Zip | 49098-8531
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Country | US
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Telephone | 269-463-3125
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Fax |
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Provider Business Mailing Address
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Address Line | 4305 DIVISION AVE S
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-3315
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Country | US
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Telephone | 616-617-9974
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMELIA FAJARDO
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Credential | MD
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Telephone | 616-617-9974
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 4301030837
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License Number State | MI
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