Provider Demographics
NPI:1508021858
Name:FASTVAX LLC
Entity Type:Organization
Organization Name:FASTVAX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SIEVERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-996-1400
Mailing Address - Street 1:1500 HORIZON DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CHALFONT
Mailing Address - State:PA
Mailing Address - Zip Code:18914-3966
Mailing Address - Country:US
Mailing Address - Phone:215-996-1400
Mailing Address - Fax:267-308-0533
Practice Address - Street 1:1500 HORIZON DR
Practice Address - Street 2:ST 120
Practice Address - City:CHALFONT
Practice Address - State:PA
Practice Address - Zip Code:18914-3966
Practice Address - Country:US
Practice Address - Phone:267-308-0534
Practice Address - Fax:267-308-0533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061592L261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center