Provider Demographics
NPI:1568086379
Name:FAI, MACKENZIE (OD)
Entity type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:
Last Name:FAI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 TIMBERWOLF PKWY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1218
Mailing Address - Country:US
Mailing Address - Phone:406-257-2020
Mailing Address - Fax:406-257-5554
Practice Address - Street 1:175 TIMBERWOLF PKWY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1218
Practice Address - Country:US
Practice Address - Phone:406-257-2020
Practice Address - Fax:406-257-5554
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty