Provider Demographics
NPI:1184095713
Name:FARZALO, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FARZALO
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 1:3500 JENNINGS RD
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 JENNINGS RD
Practice Address - Street 2:
Practice Address - City:WHITMORE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48189-9506
Practice Address - Country:US
Practice Address - Phone:734-550-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion