Provider Demographics
NPI:1144776170
Name:FOGAL, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FOGAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 TORO CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6426
Mailing Address - Country:US
Mailing Address - Phone:775-852-1078
Mailing Address - Fax:
Practice Address - Street 1:4310 TORO CT
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6426
Practice Address - Country:US
Practice Address - Phone:775-852-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1821451675Medicaid