Provider Demographics
NPI:1578126033
Name:FANOULA LLC
Entity Type:Organization
Organization Name:FANOULA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:FANI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOURAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSED
Authorized Official - Phone:917-284-4268
Mailing Address - Street 1:14550 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3031
Mailing Address - Country:US
Mailing Address - Phone:917-284-4268
Mailing Address - Fax:
Practice Address - Street 1:14550 19TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-3031
Practice Address - Country:US
Practice Address - Phone:917-284-4268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-19
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty