Provider Demographics
NPI:1700531852
Name:FEDOR, ALLEN LLOYD
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:LLOYD
Last Name:FEDOR
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 1:17109 440TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLDINGFORD
Mailing Address - State:MN
Mailing Address - Zip Code:56340-9756
Mailing Address - Country:US
Mailing Address - Phone:320-493-5465
Mailing Address - Fax:
Practice Address - Street 1:17109 440TH ST
Practice Address - Street 2:
Practice Address - City:HOLDINGFORD
Practice Address - State:MN
Practice Address - Zip Code:56340-9756
Practice Address - Country:US
Practice Address - Phone:320-493-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty