Provider Demographics
NPI:1912584848
Name:DR FADEZ
Entity Type:Organization
Organization Name:DR FADEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED HAIR LOSS SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DELCID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-353-5501
Mailing Address - Street 1:302 SW TULIP BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6299
Mailing Address - Country:US
Mailing Address - Phone:772-353-5501
Mailing Address - Fax:
Practice Address - Street 1:302 SW TULIP BLVD STE B
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6299
Practice Address - Country:US
Practice Address - Phone:772-353-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty