Provider Demographics
NPI:1194201822
Name:FAIN, MICHAEL JAMES (HAS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:FAIN
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-8404
Mailing Address - Country:US
Mailing Address - Phone:541-459-6111
Mailing Address - Fax:
Practice Address - Street 1:301 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-8404
Practice Address - Country:US
Practice Address - Phone:541-459-6111
Practice Address - Fax:541-459-6111
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-533729237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty