Provider Demographics
NPI:1861905804
Name:FANDRICH, ZACHARY D (ATC)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:D
Last Name:FANDRICH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1791 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5648
Mailing Address - Country:US
Mailing Address - Phone:928-855-4248
Mailing Address - Fax:
Practice Address - Street 1:1791 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5648
Practice Address - Country:US
Practice Address - Phone:928-855-4248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer