Provider Demographics
NPI:1538643119
Name:DAEDOUE, FAHD
Entity Type:Individual
Prefix:
First Name:FAHD
Middle Name:
Last Name:DAEDOUE
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 1:435 KINGSCOTE LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-4675
Mailing Address - Country:US
Mailing Address - Phone:804-549-7775
Mailing Address - Fax:
Practice Address - Street 1:435 KINGSCOTE LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-4675
Practice Address - Country:US
Practice Address - Phone:804-549-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA002-00670711343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)