Basic Information
| Provider Information | |||||||||
| NPI: | 1568086379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAI | ||||||||
| FirstName: | MACKENZIE | ||||||||
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| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 NW 12TH AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BATTLE GROUND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986049145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606870755 | ||||||||
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| Practice Location | |||||||||
| Address1: | 815 W 2000 N | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017764426 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2020 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD61122557 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.