1629152764 NPI number — MR. ALLEN MICHAEL FREY R.T.

Table of content: MR. ALLEN MICHAEL FREY R.T. (NPI 1629152764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629152764 NPI number — MR. ALLEN MICHAEL FREY R.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREY
Provider First Name:
ALLEN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.T.
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:
1629152764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 75 BOX 189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87520-9712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-756-7219
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
JICARILLA APACHE HEALTH CARE CENTER
Provider Second Line Business Practice Location Address:
12000 STONE LAKE ROAD
Provider Business Practice Location Address City Name:
DULCE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-759-3291
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2006

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: 2471C3402X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000K3526 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSZ196 . This is a "MEDICARE PART B" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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