Provider Demographics
NPI:1457499105
Name:FAIRCHILD, VICTOR L
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:L
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22435 SE 240TH ST APT H303
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6071
Mailing Address - Country:US
Mailing Address - Phone:425-246-2030
Mailing Address - Fax:
Practice Address - Street 1:22647 NE INGLEWOOD HILL RD
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-7105
Practice Address - Country:US
Practice Address - Phone:425-868-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006936225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist