Provider Demographics
NPI:1558442616
Name:FAIRLEY, COLIN M
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:M
Last Name:FAIRLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ADAPT
Other - Middle Name:
Other - Last Name:MOBILTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:122 BUISNESS CIRCLE
Mailing Address - Street 2:P.O. BOX 706
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160
Mailing Address - Country:US
Mailing Address - Phone:972-524-8625
Mailing Address - Fax:972-524-8626
Practice Address - Street 1:122 BUISNESS CIRCLE
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160
Practice Address - Country:US
Practice Address - Phone:972-524-8625
Practice Address - Fax:972-524-8626
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1130450001Medicare ID - Type Unspecified