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General NPI Number Information
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NPI Number | 1659552057
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Entity Type | Organization
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Legal Business Name | JOHN ANTON FACKENTHALL
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Dates
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Enumeration Date | 11/14/2007
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Last Update Date | 01/03/2013
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Provider Practice Location Address
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Address Line | 1312 E ISAACS AVE
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City | WALLA WALLA
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State | WA
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Zip | 99362-2152
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Country | US
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Telephone | 509-525-4100
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Fax | 509-529-7033
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Provider Business Mailing Address
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Address Line | 1312 E ISAACS AVE
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City | WALLA WALLA
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State | WA
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Zip | 99362-2152
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Country | US
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Telephone | 509-525-4100
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Fax | 509-529-7033
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. JOHN ANTON FACKENTHALL
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Credential | DO
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Telephone | 509-525-4100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OP00000703
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License Number State | WA
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