Provider Demographics
NPI:1043316599
Name:CARROLL-FACKLER, PATRICIA MARIANN (DC)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:MARIANN
Last Name:CARROLL-FACKLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 WEST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875
Mailing Address - Country:US
Mailing Address - Phone:419-342-3473
Mailing Address - Fax:
Practice Address - Street 1:177 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875
Practice Address - Country:US
Practice Address - Phone:419-342-3473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2289111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U61215Medicare UPIN
FA0802272Medicare ID - Type Unspecified