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NPI Code Detail

MEDICARE: MR. JEPHTE FANOR

MEDICARE: MR. JEPHTE FANOR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1033328893
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JEPHTE FANOR
Provider Business Mailing Address
First Line : 66 COLLINS AVE
Second Line :
City : RANDOLPH
State : MA
Zip : 02368-2048
Country : US
Telephone Number : 781-963-9301
Fax Number :
Provider Business Practice Location Address
First Line : 317 BLUE HILL AVE
Second Line :
City : DORCHESTER
State : MA
Zip : 02121-4302
Country : US
Telephone Number : 617-427-4470
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/21/2007
Last Update Date : 07/08/2007

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