Provider Demographics
NPI:1023836400
Name:ALLEN, MICHAEL DAVID
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-3018
Mailing Address - Country:US
Mailing Address - Phone:858-899-4495
Mailing Address - Fax:909-260-6730
Practice Address - Street 1:3602 INLAND EMPIRE BLVD STE C315
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4986
Practice Address - Country:US
Practice Address - Phone:858-899-4495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker