MEDICARE: MRS. HAZEL ROJO FAELLACI LPN

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
1	164W00000X	Licensed Practical Nurse	4703099266	MI

General Provider Information

NPI Number	:	1881169167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HAZEL ROJO FAELLACI LPN

Provider Business Mailing Address
First Line	:	5711 JACKSON AVE
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-8932
Country	:	US
Telephone Number	:	906-630-2789
Fax Number	:

Provider Business Practice Location Address
First Line	:	5711 JACKSON AVE
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-8932
Country	:	US
Telephone Number	:	906-630-2789
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2018
Last Update Date	:	10/12/2018

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