Provider Demographics
NPI:1871820977
Name:ALLEN, MARCIA (BA)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE B2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1350
Mailing Address - Country:US
Mailing Address - Phone:505-872-3668
Mailing Address - Fax:505-888-7041
Practice Address - Street 1:5011 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE B2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1350
Practice Address - Country:US
Practice Address - Phone:505-872-3668
Practice Address - Fax:505-888-7041
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM202635927225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1881667806Medicaid
NM05756863Medicaid
NM5518920001Medicare PIN
NM5518920001Medicare NSC
NM1881667806Medicare PIN
NM1881667806Medicare NSC