Provider Demographics
NPI:1578904769
Name:FAKHORI, EMANUEL LOFTI
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:LOFTI
Last Name:FAKHORI
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 1:12145 LANDING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4635
Mailing Address - Country:US
Mailing Address - Phone:646-505-9427
Mailing Address - Fax:
Practice Address - Street 1:12145 LANDING GREEN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4635
Practice Address - Country:US
Practice Address - Phone:646-505-9427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC201315400053343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)