Provider Demographics
NPI:1538670187
Name:AHLGRIM, JORDYN
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:AHLGRIM
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 1:3415 N BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 N BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2309
Practice Address - Country:US
Practice Address - Phone:505-635-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-22
Last Update Date:2017-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist