| Organization Name: | AMELIA FAJARDO FAMILY MEDICAL CLINIC PC |
| NPI Number: | 1265733356 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | AMELIA FAJARDO (OWNER) |
| Mailing Address: | 450 Medical Park Dr Suite 100 Watervliet |
| State: | MI US |
| Postal Code: | 490988531 |
| Phone Number: | 2694633125 |
| Fax Number: | |
| NPI Enumeration Date: | 11/05/2010 |
| NPI Last Update Date: | 05/11/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 4301030837 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |