Provider Demographics
NPI:1255189221
Name:FANFAN, LOUIS SR
Entity type:Individual
Prefix:MRS
First Name:LOUIS
Middle Name:
Last Name:FANFAN
Suffix:SR
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 1:132 CHANNING DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1254
Mailing Address - Country:US
Mailing Address - Phone:302-591-8141
Mailing Address - Fax:
Practice Address - Street 1:132 CHANNING DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-1254
Practice Address - Country:US
Practice Address - Phone:302-591-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1713456343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)