Provider Demographics
NPI:1740530088
Name:DR FAZZIO LLC
Entity type:Organization
Organization Name:DR FAZZIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZZIO
Authorized Official - Suffix:III
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:907-456-3302
Mailing Address - Street 1:29 COLLEGE RD
Mailing Address - Street 2:SUITE 8B-1
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-1739
Mailing Address - Country:US
Mailing Address - Phone:907-456-3302
Mailing Address - Fax:907-374-8060
Practice Address - Street 1:29 COLLEGE RD
Practice Address - Street 2:SUITE 8B-1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-1739
Practice Address - Country:US
Practice Address - Phone:907-456-3302
Practice Address - Fax:907-374-8060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK166111N00000X
261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1616561Medicaid
AK1000554Medicaid