Provider Demographics
NPI:1568086379
Name:FAI, MACKENZIE (OD)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:
Last Name:FAI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NW 12TH AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-9145
Mailing Address - Country:US
Mailing Address - Phone:360-687-0755
Mailing Address - Fax:
Practice Address - Street 1:815 W 2000 N
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1632
Practice Address - Country:US
Practice Address - Phone:801-776-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61122557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty