Provider Demographics
NPI:1689389785
Name:FAIRLEY, JOSEPH KENNETH III (CP)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:KENNETH
Last Name:FAIRLEY
Suffix:III
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:480 BROADWAY STE LL14
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-6727
Mailing Address - Country:US
Mailing Address - Phone:518-430-2034
Mailing Address - Fax:
Practice Address - Street 1:480 BROADWAY STE LL14
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6727
Practice Address - Country:US
Practice Address - Phone:518-430-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CP004468335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier