Provider Demographics
NPI:1912794611
Name:FAIRCLOTH, CHRISTOPHER W (LMBT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:W
Last Name:FAIRCLOTH
Suffix:
Gender:
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6336 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-8556
Mailing Address - Country:US
Mailing Address - Phone:919-614-4527
Mailing Address - Fax:
Practice Address - Street 1:136 US 70 HWY E
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3982
Practice Address - Country:US
Practice Address - Phone:919-614-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist