Individual
GLENN ALBERT FAIRALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2532 NW ASHLEY DR, ALBANY, OR 97321-1395
(541) 979-1019
Mailing address
PO BOX 741, ALBANY, OR 97321-0252
(541) 979-1019
Taxonomy
Speciality
Code
Description
License number
State
156F00000X
Technician/Technologist
Primary
88193
OR
Other
Enumeration date
02/06/2019
Last updated
02/06/2019
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