Provider Demographics
NPI:1104240340
Name:FATA INC.
Entity type:Organization
Organization Name:FATA INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DAC
Authorized Official - Phone:909-829-2349
Mailing Address - Street 1:9773 SIERRA AVE
Mailing Address - Street 2:9773 SIERRA AVE. #H7
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6716
Mailing Address - Country:US
Mailing Address - Phone:909-829-2349
Mailing Address - Fax:909-829-2349
Practice Address - Street 1:9773 SIERRA AVE
Practice Address - Street 2:9773 SIERRA AVE. #H7
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6716
Practice Address - Country:US
Practice Address - Phone:909-829-2349
Practice Address - Fax:909-829-2349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FATA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12047246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, MedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC12047OtherACUPUNCTURE