1679544381 NPI number — GLENN RIEGO PUERTOLLANO MD

Table of content: GLENN RIEGO PUERTOLLANO MD (NPI 1679544381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679544381 NPI number — GLENN RIEGO PUERTOLLANO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUERTOLLANO
Provider First Name:
GLENN
Provider Middle Name:
RIEGO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679544381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2748
Provider Second Line Business Mailing Address:
RED RIVER HEALTH CARE
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-2748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-432-3221
Provider Business Mailing Address Fax Number:
606-437-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321C EAST COLLEGE AVE
Provider Second Line Business Practice Location Address:
RED RIVER HEALTH CARE
Provider Business Practice Location Address City Name:
STANTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-663-9797
Provider Business Practice Location Address Fax Number:
606-663-9470
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  38924 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64094683 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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