Provider Demographics
NPI:1629152764
Name:FREY, ALLEN MICHAEL (RT)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:MICHAEL
Last Name:FREY
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 75 BOX 189
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-9712
Mailing Address - Country:US
Mailing Address - Phone:505-756-7219
Mailing Address - Fax:
Practice Address - Street 1:JICARILLA APACHE HEALTH CARE CENTER
Practice Address - Street 2:12000 STONE LAKE ROAD
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid