Provider Demographics
NPI:1659552057
Name:JOHN ANTON FACKENTHALL
Entity Type:Organization
Organization Name:JOHN ANTON FACKENTHALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTON
Authorized Official - Last Name:FACKENTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:509-525-4100
Mailing Address - Street 1:1312 E ISAACS AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2152
Mailing Address - Country:US
Mailing Address - Phone:509-525-4100
Mailing Address - Fax:509-529-7033
Practice Address - Street 1:1312 E ISAACS AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2152
Practice Address - Country:US
Practice Address - Phone:509-525-4100
Practice Address - Fax:509-529-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1252808Medicaid
WAE20270Medicare UPIN
WAG8850948Medicare PIN